Stimulation of liver regeneration after hepatectomy in mice by injection of bone marrow mesenchymal stem cells via the portal vein

AIM

To investigate whether mouse bone marrow mesenchymal stem cells (BMC) stimulate liver regeneration after partial hepatectomy.

METHODS

Isolated BMCs were purified by density gradient centrifugation. We performed a 70% hepatectomy in male BALB/c mice followed by injection of BMCs into the portal vein (PV-BMC group), or the tail vein (IV-BMC group), or of saline into the portal vein (control group).

RESULTS

The wet weight of the liver remnant increased significantly in the PV-BMC group at 3 and 5 days after hepatectomy compared with the IV-BMC and control groups. The Ki-67 labeling index revealed that the increase to result from stimulation of DNA synthesis. The constitutive interleukin-6 and hepatocyte growth factor mRNAs in the remnant liver tended to increase in the PV-BMC group at 3 days after hepatectomy.

CONCLUSIONS

These results demonstrated that BMC injection into the portal vein enhanced liver growth after partial hepatectomy in mice.

Phase II trial of preoperative S-1 plus cisplatin followed by surgery for initially unresectable locally advanced gastric cancer

BACKGROUND

The aim of this study was to evaluate the efficacy and feasibility of preoperative chemotherapy with S-1 plus cisplatin in patients with initially unresectable locally advanced gastric cancer.

METHODS

We enrolled patients with initially unresectable locally advanced gastric cancer because of severe lymph node metastases or invasion of adjacent structures. Preoperative chemotherapy consisted of S-1 at 80 mg/m(2) divided in two daily doses for 21 days and cisplatin at 60 mg/m(2) intravenously on day 8, repeated every 35 days. If a tumor decreased in size, patients received 1 or 2 more courses. Surgery involved radical resection with D2 lymphadenectomy.

RESULTS

Between December 2000 and December 2007, 27 patients were enrolled on the study. No CR was obtained, but PR was seen in 17 cases, and the response rate was 63.0%. Thirteen patients (48.1%) had R0 resections. There were no treatment related deaths. The median overall survival time (MST) and the 3-year overall survival (OS) of all patients were 31.4 months and 31.0%, respectively. Among the 13 patients who underwent curative resection, the median disease-free survival (DFS) and the 3-year DFS were 17.4 months and 23.1%, respectively. The MST and the 3-year OS were 50.1 months and 53.8%, respectively. The most common site of initial recurrence after the R0 resection was the para-aortic lymph nodes.

CONCLUSIONS

Preoperative S-1 plus cisplatin can be safely delivered to patients undergoing radical gastrectomy. This regimen is promising as neoadjuvant chemotherapy for resectable gastric cancer. For initially unresectable locally advanced gastric cancer, new trials using more effective regimens along with extended lymph node dissection are necessary.

Preoperative laparoscopic examination using surgical manipulation and ultrasonography for pancreatic lesions

BACKGROUND AND STUDY AIMS

Unnecessary laparotomies in patients with advanced pancreatic disease are unlikely to provide any benefits and may compromise both the quality and duration of survival. The purpose of this study was to determine the contribution of laparoscopy and laparoscopic ultrasound to the diagnosis or staging, or both, of pancreatic lesions.

PATIENTS AND METHODS

Fifty-two patients were diagnosed preoperatively with pancreatic cancer. The diagnoses made by laparoscopic ultrasonography (LUS) were compared with those made prior to the operation. Laparoscopic visualization of the body of the pancreas was obtained via an infragastric approach. For the laparoscopic examination of the head of the pancreas, a retroduodenal approach was used.

RESULTS

In 52 patients with cancer of the pancreatic head and body, unresectable findings were observed in 13 patients. Portal vein displacement without other unresectable findings was evident in six patients using LUS, and was confirmed at exploratory laparotomy in five patients. The surgical approaches were changed, with seven patients undergoing an open exploration for biliary drainage and the other six patients receiving endoscopic endoprostheses. In six of the 52 patients, LUS-guided needle biopsies and frozen-section examinations detected chronic pancreatitis (n = 4), a malignant lymphoma (n = 1), and an abdominal tuberculosis (n = 1), which were diagnosed preoperatively as pancreatic cancers and cysts. Only one patient undergoing the laparoscopic procedure had acute pancreatitis; this patient was treated conservatively.

CONCLUSIONS

LUS, when combined with laparoscopic manipulations, may overcome many of the limitations of laparoscopy alone in the investigation of pancreatic lesions by providing an accurate diagnosis and assessment of the size and extent of the local dissemination.

A new method for tolerance induction: busulfan administration followed by intravenous injection of neuraminidase-treated donor bone marrow

The portal venous (p.v.) administration of foreign cells induces donor-specific tolerance. Recently, we have demonstrated that the p.v. administration of donor cells elicits donor-specific tolerance across major histocompatibility complex barriers. In the present study, utilizing the intrahepatic tolerance-inducing system, we have established a new method for organ transplantation using both busulfan ([Bu] to provide a sufficient "space" for the donor hematopoietic cells to expand in the recipient) and neuraminidase ([Neu] to enhance the trapping of i.v.-injected cells in the liver). Radiolabeled bone marrow cells (BMCs) were found to exclusively accumulate in the livers of the recipients as a result of the Neu treatment. Furthermore, hematopoietic progenitors (forming hematopoietic foci) in the accumulated BMCs were retained in the recipient livers for at least 18 days. C57BL/6 (B6) mice that had been transplanted with skins of BALB/c mice immediately after the injection of BALB/c BMCs showed a 90% skin graft survival rate over 400 days as a result of using the combination of injecting 50 mg/kg Bu into the B6 mice and treatment of the BALB/c BMCs with 0.25 U/ml Neu (50 Bu + 0.25 Neu). However, the survival rate significantly decreased when either the Bu or Neu treatment was omitted. In tolerant recipients, microchimerism was observed in the various hematolymphoid organs. T cells collected from the tolerant recipients suppressed proliferative responses to the donor-alloantigens but enhanced the production of Th2 and Th3 cytokines. These findings suggest that the enhanced retention of donor BMCs in the recipient livers as a result of the Bu and Neu treatments efficiently induces tolerance induction. Therefore, this "single-day protocol" would be of great advantage for human organ transplantation.

Laparoscopic cholecystectomy and choledocholithotomy in patients with a previous gastrectomy

BACKGROUND

An increased incidence of cholelithiasis has been widely reported after truncal vagotomy and after gastric resection. In the early phase of patient selection, previous gastrectomy has been considered a relative contraindication to laparoscopic cholecystectomy (LC). In this study, we examined the management of LC in patients with previous gastrectomy.

STUDY DESIGN

LC was attempted on 1,260 consecutive patients. Of these patients, 29 had a previous gastrectomy. Surgical procedures that had been performed included Billroth I gastrectomies (15), Billroth II gastrectomies (10), and total gastrectomies (4). There were 23 cases of cholelithiasis, 4 chronic cholecystitis, 2 gallbladder polyps, I porcelain gallbladder, and I gallbladder cancer. Nine patients were diagnosed with stones in their common bile duct or common hepatic duct.

RESULTS

Preoperatively, seven of nine patients with common bile duct stones were subjected to endoscopic sphincterotomy, and the stones were removed successfully from five of these patients. In the remaining two patients, common bile duct stones were removed by laparoscopic choledocholithotomy by choledochotomy. The LC was completed in 26 patients (90%) who had undergone previous gastrectomy. In 449 patients who had previous abdominal surgery without a gastrectomy, only 4 patients (0.9%) required open surgery. In contrast, three patients (10%) with previous gastrectomy required open surgery. No major complications were recorded in this study series, and no residual or retained stones were seen during a followup period of 3 months.

CONCLUSIONS

Clear visualization of anatomic structures and landmarks, and scrupulous hemostasis are needed to perform a safe LC in these patients. We conclude that in our study patients, a previous gastrectomy is considered an indication for LC and laparoscopic choledochotomy.

Cold preservation of rat pancreatic islets just above the freezing point using University of Wisconsin solution

AIMS

To confirm whether rat islets stored at a temperature just above the freezing point using University of Wisconsin (UW) solution would remain viable for the short term.

METHODOLOGY

Rat islets were stored for 24 hours in UW solution, either at 4 degrees C or at -0.6 degrees C (just above the specific freezing point of the UW solution). After cold storage, the islets were assessed for in vitro viability by static incubation and for in vivo viability by a transplantation study. One thousand islets preserved under different conditions were injected intraportally into a streptozotocin-induced diabetic rat as an isograft. Four weeks after the transplantation, an intravenous glucose tolerance test was performed.

RESULTS

Islets stored at -0.6 degrees C showed higher insulin secretion rates than those stored at 4 degrees C on a static challenge. The interval from transplantation to the achievement of normoglycemia was also shorter in the -0.6 degrees C group than in the 4 degrees C group. After islet transplantation, the daily nonfasting plasma glucose concentration was higher in the 4 degrees C group than in the -0.6 degrees C group. When compared with the 4 degrees C group, the -0.6 degrees C group showed lower blood glucose values during all investigational periods on an intravenous glucose tolerance test.

CONCLUSION

Islet preservation at -0.6 degrees C using UW solution is more advantageous for short term.

Laparoscopic splenectomy for a lymphangioma of the spleen: report of a case

We present the first case report of a successful laparoscopic complete excision of a splenic lymphangioma. The splenic tumor was preoperatively diagnosed to be a lymphangioma by the combined modalities of ultrasonography, computed tomography, magnetic resonance imaging, and angiography. A laparoscopic splenectomy was subsequently performed and the pathological examination of the mass confirmed the diagnosis of a lymphangioma. Based on the above findings, a laparoscopic splenectomy is recommended when a splenic tumor is suspected to be either benign or borderline.

Laparoscopic management of bile duct and bowel injury during laparoscopic cholecystectomy

Accidental injuries to the bile duct and bowel are significant risks of laparoscopic surgery and sometimes require conversion to open surgery. Although some of the injuries related to laparoscopic cholecystectomy can be managed by endoscopic techniques, laparoscopic surgery is not yet sufficiently perfected. We investigated the efficacy of laparoscopic management combined with endoscopic tube or stent insertion in cases of bile duct and bowel injuries during laparoscopic cholecystectomy. Laparoscopic cholecystectomy was attempted on 1,190 consecutive patients between April 1992 and June 1999. The first 70 patients underwent only preoperative intravenous infusion cholangiography (IVC), and the remaining 1,120 patients were subjected to both preoperative IVC and intraoperative cholangiography. We experienced 16 cases of bile duct injury (1.4%). Five patients with circumferential injuries of the bile duct were converted to open surgery for biliary reconstruction. The other 11 patients with partial laceration injuries of the bile duct and biliary leakage from the cystic duct underwent a laparoscopic simple closure technique. In 10 of these patients, an endoscopic tube or stent was inserted on the day after surgery to facilitate biliary decompression and drainage. Bowel injuries occurred in seven patients (0.6%). Three intestinal injuries were due to careless technique, and two duodenal injuries and two intestinal injuries were related to dense adhesions. All of these injuries were successfully repaired using laparoscopic techniques, autosuturing devices, or extracorporeal suturing via the umbilical incision. No postoperative complications were identified. We concluded that the biliary injury site could be closed with a laparoscopic technique so long as the biliary injury was not circumferential. Bowel injuries also could be repaired laparoscopically.

FK506, but not cyclosporin A, prevents mitochondrial dysfunction during hypoxia in rat hepatocytes

Hepatic ischemia/reperfusion injury occurs in the clinical situations including liver transplantation. FK506 and cyclosporin A (CsA) are reported to be hepatotrophic agents in addition to being a powerful immunosuppressive agent. Studies were performed to determine whether the drugs influence a mitochondrial dysfunction under the hypoxic conditions in primary culture model of rat hepatocytes. The Anaeropack system was used for cell culture to create a hypoxia. Cells were treated with FK506 or CsA under the normoxic and hypoxic conditions. Hypoxia markedly decreased intracellular adenosine 5'-triphosphate (ATP) contents and the ketone body ratio (KBR, acetoacetate/beta-hydroxybutyrate) in culture medium as compared with normoxia. FK506 prevented the decreases of ATP contents and the KBR. In contrast, CsA had no effect on either ATP contents or the KBR. FK506, but not CsA, increased the KBR under the normoxic conditions. Under the hypoxic conditions, heat shock protein 70 (Hsp70) was detected after reoxygenation. FK506 enhanced the induction of Hsp70, but CsA again had no effect on Hsp70 induction. These results indicate that FK506 protects the hypoxia injury in part by preventing the mitochondrial dysfunction in concert with the enhancement of heat shock response in hepatocytes.

Perioperative blood transfusion in hepatocellular carcinomas: influence of immunologic profile and recurrence free survival

BACKGROUND

The postoperative recurrence of hepatocellular carcinomas (HCC) associated with perioperative blood transfusion has been the subject of controversy. The authors prospectively investigated the relation between perioperative allogeneic blood transfusions, the recurrence free survival, and the immunologic profiles of patients with HCC who had undergone curative hepatic resections.

METHODS

One hundred eight patients were divided into two groups: a transfused group (n = 53) and a nontransfused group (n = 55), according to their perioperative transfusion history. The subsets of lymphoid cells, natural killer cell activity and the phytohemagglutinin (PHA) response were all measured preoperatively, and at 1, 2, and 4 weeks and at 3 and 6 months after the hepatectomy. The recurrence free survival rate then was compared between these two groups.

RESULTS

There were no significant differences between these two groups with respect to histologic findings, clinical stage, type of resection, pathologic data, and the recurrence free survival rate. Postoperative levels of the CD8 in the transfused group were elevated as compared with the nontransfused group, and the PHA response of the transfused patients was significantly increased at 7 postoperative days. Natural killer cell activity of the transfused patients was decreased at 7 postoperative days, as compared with the nontransfused patients, but there was no significant difference.

CONCLUSIONS

Although allogeneic blood transfusion may have immunosuppressive effects, perioperative blood transfusions did not influence the cancer free survival rate in patients with hepatocellular carcinoma.

Ruptured dissecting aneurysm in bilateral iliac arteries caused by Ehlers-Danlos syndrome type IV: report of a case

Ehlers-Danlos syndrome (EDS) is an inherited disorder of connective tissue characterized by hyperextensible skin, hypermobile joints, and abnormalities of the cardiovascular system. Ten types and several subtypes of EDS have so far been recognized based on genetic, clinical, and biochemical characteristics. The spectrum of the disorder varies from mild to life-threatening vascular complications. EDS type IV is a particularly dangerous form with a lethal spontaneous rupture of the major arteries and aneurysmal formation. We present herein a case of a ruptured dissecting aneurysm in the bilateral iliac arteries caused by EDS type IV. A previously healthy 33-year-old man without any physical features of this connective tissue disorder experienced a metachronous vascular rupture two times. Successful synthetic bypass grafting was performed with great difficulty. The diagnosis of EDS type IV was made afterwards based on an electrophoresis analysis of a skin biopsy specimen which revealed a lack of type III collagen. Surgical intervention in cases of arterial complications in EDS type IV patients have been reported to be both difficult and frequently unsuccessful. The early clinical recognition of this syndrome is therefore of great importance due to the hazards of such surgical therapies.

Functional hepatic volume measured by technetium-99m-galactosyl-human serum albumin liver scintigraphy: comparison between hepatocyte volume and liver volume by computed tomography

OBJECTIVES

We investigated the usefulness of measuring the functional hepatic volume by single-photon emission CT with 99m-technetium galactosyl-human serum albumin scintigraphy (GSA-LV). We then compared this value to the total hepatocyte volume and the hepatic volume determined from CT (CT-LV) in the patients with hepatobiliary tumors.

METHODS

Forty-seven patients were divided into two groups, the SM group (subsegmentectomy and monosegmentectomy) and the DT group (disegmentectomy and trisegmentectomy). These groups were further divided into subgroups with or without chronic hepatitis or cirrhosis. The GSA-LV, CT-LV, and the total hepatocyte volume were then calculated. The GSA-LV and CT-LV measurements were performed preoperatively, at 2 and 4 wk, and at 3 and 6 months after surgery.

RESULTS

The preoperative GSA-LV values were significantly correlated with the hepatocyte volume and the 15-min retention rate of indocyanine green (ICGR15). Similarly, the hepatocyte volume correlated well with the CT-LV and ICGR15. However, the CT-LV was correlated only with the ICGR15. Recovery of the GSA-LV in the DT group was delayed, and about 90% of the volumetric and functional regeneration was observed within 6 months after the hepatectomy. In contrast, the CT-LV of DT group patients with normal liver remnants returned to approximately 90% of their initial volume within 1 month after the hepatectomy, whereas patients with injured livers regenerated gradually and regained approximately 80% of their preoperative value by 6 months after the hepatectomy.

CONCLUSIONS

We conclude that the measurement of functional hepatic volume using the GSA-LV is useful in fully evaluating hepatic function based on hepatocyte volume.

Functional hepatic volume measured by technetium-99m-galactosyl-human serum albumin liver scintigraphy: comparison between hepatocyte volume and liver volume by computed tomography

OBJECTIVES

We investigated the usefulness of measuring the functional hepatic volume by single-photon emission CT with 99m-technetium galactosyl-human serum albumin scintigraphy (GSA-LV). We then compared this value to the total hepatocyte volume and the hepatic volume determined from CT (CT-LV) in the patients with hepatobiliary tumors.

METHODS

Forty-seven patients were divided into two groups, the SM group (subsegmentectomy and monosegmentectomy) and the DT group (disegmentectomy and trisegmentectomy). These groups were further divided into subgroups with or without chronic hepatitis or cirrhosis. The GSA-LV, CT-LV, and the total hepatocyte volume were then calculated. The GSA-LV and CT-LV measurements were performed preoperatively, at 2 and 4 wk, and at 3 and 6 months after surgery.

RESULTS

The preoperative GSA-LV values were significantly correlated with the hepatocyte volume and the 15-min retention rate of indocyanine green (ICGR15). Similarly, the hepatocyte volume correlated well with the CT-LV and ICGR15. However, the CT-LV was correlated only with the ICGR15. Recovery of the GSA-LV in the DT group was delayed, and about 90% of the volumetric and functional regeneration was observed within 6 months after the hepatectomy. In contrast, the CT-LV of DT group patients with normal liver remnants returned to approximately 90% of their initial volume within 1 month after the hepatectomy, whereas patients with injured livers regenerated gradually and regained approximately 80% of their preoperative value by 6 months after the hepatectomy.

CONCLUSIONS

We conclude that the measurement of functional hepatic volume using the GSA-LV is useful in fully evaluating hepatic function based on hepatocyte volume.

Hypoxia and heat inhibit inducible nitric oxide synthase gene expression by different mechanisms in rat hepatocytes

Ischemia/reperfusion contributes to the hepatic injury in resection and transplantation of the liver. However, the precise mechanisms involved in hypoxia stress remain to be clarified. Pro-inflammatory cytokines including interleukin 1beta (IL-1beta) induce a gene expression of inducible nitric oxide synthase (iNOS) and produce nitric oxide, which exerts either a cytoprotective or toxic effect. In this report, we found that hypoxia and heat markedly inhibited the induction of nitric oxide production stimulated by IL-1beta in rat cultured hepatocytes. Both treatments also abolished the induction of iNOS protein and mRNA. However, hypoxia could not prevent either degradation of an inhibitory protein (IkappaBalpha) of nuclear factor-kappaB (NF-kappaB) or translocation of NF-kappaB to the nucleus, whereas heat inhibited both of the IkappaBalpha degradation and NF-kappaB translocation. Transfection experiments with iNOS promoter construct revealed that hypoxia as well as heat significantly inhibited the transactivation of iNOS gene. Further, a hypoxia-response element located in the promoter was not involved in the inhibition of iNOS induction by hypoxia. These results indicate that hypoxia and heat suppress iNOS gene induction at the transcriptional level through different mechanisms. Reduction of nitric oxide production under hypoxic conditions may be implicated in the cellular damage or protection during hepatic ischemia/reperfusion.

Recombinant human hepatocyte growth factor protects the liver against hepatic ischemia and reperfusion injury in rats

BACKGROUND

Recent evidence indicates that hepatocyte growth factor (HGF) has a cytoprotective effect against hepatic injury caused by hepatotoxins and inflammatory cytokines. Studies were performed to determine whether HGF influences the survival rate of rats subjected to hepatic warm ischemia/reperfusion (WI/Rp) injury.

METHODS

Male Sprague-Dawley rats were subjected to total or segmental hepatic ischemia by occluding the hepatic artery, portal vein, and bile duct with a microvascular clip. Rats were treated with four intravenous injections of recombinant human HGF (rhHGF 1 mg/kg) or the vehicle 72, 48, 24, and 12 h before surgery.

RESULTS

None of the eight animals in the control group were alive 12 h after total hepatic WI/Rp. Seven of eight animals in the rhHGF-treated group were alive more than 2 days after the reperfusion. In the model of segmental hepatic ischemia, rhHGF inhibited the increase in cytokine-induced neutrophil chemoattractant in serum. The number of neutrophils infiltrating the liver was significantly lower in the rhHGF-treated group than in the control group. rhHGF prevented increases in the activity of serum alanine transaminase and in hepatic necrosis. Experiments with proliferating cell nuclear antigen staining demonstrated that hepatocyte proliferation markedly increased in rhHGF-treated rats as compared with controls.

CONCLUSIONS

These results indicate that HGF facilitates recovery of the liver from hepatic WI/Rp injury, at least in part through the prevention of neutrophil infiltration and the activation of hepatocyte proliferation.

Increased extra domain-A containing fibronectin and hepatic dysfunction during septic response: an in vivo and in vitro study

A massive inflammatory reaction resulting from systemic cytokine release is the common pathway underlying sepsis or multiple organ dysfunction. The role of extra domain sequence A-containing fibronectin (EDA+FN) formation during the septic response is not known. The present study investigates the role of EDA+FN during the septic response under in vitro and in vivo conditions. The direct effects of interleukin-1, interleukin-6, and tumor necrosis factor-alpha on EDA+FN production were evaluated in primary cultured human hepatocytes and fibroblasts. Serial plasma EDA+FN levels were measured using an enzyme-linked immunosorbent assay in 24 patients who developed postoperative sepsis following general abdominal surgery of which there were 17 survivors and 7 non-survivors. EDA+FN secretion was significantly increased in cultured hepatocytes but not fibroblasts at 24 and 48 h following exposure to IL-1 compared to controls. In the clinical setting plasma EDA+FN levels in non-survivors were significantly higher than in survivors. Moreover, the EDA+FN levels were correlated closely with liver function tests. EDA+FN levels may represent a specific marker of vascular injury or systemic inflammatory response syndrome that is associated with an adverse clinical outcome.

Nitric oxide production and hepatic dysfunction in patients with postoperative sepsis

1. Although hepatic function is well known to deteriorate following bacterial infection, the underlying mechanisms remain poorly understood. We have previously reported that nitric oxide (NO) radical leads to a decrease in the ketone body ratio (KBR) and in ATP content due to the inhibition of mitochondrial electron transport in primary cultured rat hepatocytes. 2. To evaluate the effects of NO radical on the liver in patients with postoperative sepsis, we analysed both the stable end-product of nitric oxide radical (NOx) as well as the arterial KBR (AKBR), which reflects liver tissue NAD+/NADH. 3. Twenty patients who had undergone general abdominal surgery and who developed postoperative sepsis were divided into two groups: (i) surviving; and (ii) non-surviving. Blood samples were collected before the development of postoperative sepsis and every 3 days until the patient either died or was discharged from hospital. 4. Plasma NOx levels in seven patients who subsequently died became progressively higher than those in the 13 surviving patients over the clinical course of postoperative sepsis. 5. In the non-surviving group, the AKBR was significantly lower than in surviving patients, indicating impaired hepatic function. In contrast, plasma NOx levels in non-surviving patients were significantly higher than in surviving patients. 6. Decreases in AKBR to levels below 0.7 in non-surviving patients followed high NOx levels. Moreover, plasma NOx levels were closely correlated with the AKBR, indicating that NO radical is associated with mitochondrial dysfunction in the liver. 7. It is likely that the overproduction of NO radical plays an important role in causing fatal metabolic disorders in patients with postoperative sepsis.

In vitro selection and characterization of a highly efficient Zn(II)-dependent RNA-cleaving deoxyribozyme

A group of highly efficient Zn(II)-dependent RNA-cleaving deoxyribozymes has been obtained through in vitro selection. They share a common motif with the '8-17' deoxyribozyme isolated under different conditions, including different design of the random pool and metal ion cofactor. We found that this commonly selected motif can efficiently cleave both RNA and DNA/RNA chimeric substrates. It can cleave any substrate containing rNG (where rN is any ribo-nucleotide base and G can be either ribo- or deoxy-ribo-G). The pH profile and reaction products of this deoxyribozyme are similar to those reported for hammerhead ribozyme. This deoxyribozyme has higher activity in the presence of transition metal ions compared to alkaline earth metal ions. At saturating concentrations of Zn(2+), the cleavage rate is 1.35 min(-1)at pH 6.0; based on pH profile this rate is estimated to be at least approximately 30 times faster at pH 7.5, where most assays of Mg(2+)-dependent DNA and RNA enzymes are carried out. This work represents a comprehensive characterization of a nucleic acid-based endonuclease that prefers transition metal ions to alkaline earth metal ions. The results demonstrate that nucleic acid enzymes are capable of binding transition metal ions such as Zn(2+)with high affinity, and the resulting enzymes are more efficient at RNA cleavage than most Mg(2+)-dependent nucleic acid enzymes under similar conditions.

An enhancement of nitric oxide production regulates energy metabolism in rat hepatocytes after a partial hepatectomy

BACKGROUND/AIMS

Infection after a liver resection often results in hepatic failure. Nitric oxide is one of the candidates which has been suspected to cause cellular dysfunction during infection in the liver. We have previously reported that the inflammatory cytokine interleukin-1beta (IL-1beta) induced the expression of the inducible nitric oxide synthase gene in primary cultured rat hepatocytes. We hypothesized that an enhancement of nitric oxide production after the resection was implicated in a change in liver energy metabolism, thus resulting in liver dysfunction.

METHODS

In this study, we performed a 70% hepatectomy or a sham operation in rats, and then isolated hepatocytes from the remnant liver by collagenase perfusion. The cultured hepatocytes were treated with cytokines including IL-1beta. The effects on nitric oxide induction, the ATP content and ketone body ratio (acetoacetate/beta-hydroxybutyrate) were then compared between the partial hepatectomized (PH) and sham-operated (control) rats.

RESULTS

IL-1beta augmented the induction of nitric oxide production two-fold in hepatocytes from the PH rats as compared to the control rats. IL-1beta markedly decreased the ATP content in the PH rats, although IL-1beta also decreased the ATP content in the control rats, but to a lesser extent. IL-1beta also decreased the ketone body ratio in both groups. The addition of L-arginine further stimulated the inhibition of the ATP levels and the ketone body ratio concomitantly with increased nitric oxide production in the PH rats. N(G)-monomethyl-L-arginine, an inhibitor of nitric oxide synthase, abolished the effects of IL-1beta on the ATP levels and ketone body ratio, as well as on the nitric oxide production.

CONCLUSIONS

These results demonstrate that the decreased ATP content observed in PH rats resulted from an increase in nitric oxide production. The decrease in ketone body ratio indicates that nitric oxide-induced mitochondrial dysfunction contributes significantly to ATP attenuation in hepatocytes. Therefore, the regulation of nitric oxide induction may be crucial for preventing liver failure after a hepatic resection.

Different responses to surgical stress between extra domain A+ and plasma fibronectins

1. Fibronectins (FN) are believed to have a role in haemorheological perturbation associated with tissue damage. Fibronectins exist in two antigenically related forms, plasma (p) and cellular fibronectin, which has the extra domain sequences A (EDA) or B (EDB). The present study was designed to determine changes in plasma p-FN and EDA + FN under different types of surgical stress. 2. Sixty-two patients were divided into three groups: (i) group A, 33 patients undergoing hepato-pancreato-biliary surgery; (ii) group B, 19 patients undergoing laparoscopic cholecystectomy; and (iii) group C, 10 patients with postoperative complications. Plasma FN and EDA + FN levels were measured in these patients undergoing different types of surgical operation and either with or without liver cirrhosis using an enzyme-linked immunosorbent assay. 3. After surgery, a significant decrease in p-FN levels and a significant increase in EDA + FN levels was observed in all patient group compared with pre-operative levels. The duration of increased EDA + FN levels, but not p-FN levels, in group A patients was significantly longer than in group B patients. Although changes in p-FN levels between patients with and without liver cirrhosis were significantly different, there were no significant differences in the EDA + FN levels between these two patient groups. 4. In conclusions, EDA + FN and p-FN levels were found to exhibit opposite responses to surgical stress. Furthermore, with greater surgical stress, greater increases in EDA + FN levels were seen. The presence of liver cirrhosis had no significant effect on EDA + FN levels during the perioperative period; however, p-FN levels were significantly affected. 5. Thus, it is suggested that plasma EDA + FN levels reflect the magnitude of surgical stress more closely than do p-FN levels.

Managing bile duct injury during and after laparoscopic cholecystectomy

Laparoscopic cholecystectomy is now the treatment of choice for gallstones, but there has been concern that bile leakage after a laparoscopic cholecystectomy is more frequent than after an open cholecystectomy. We have experienced 16 patients with bile duct injury after a laparoscopic cholecystectomy. Five patients had a circumferential injury to the major bile duct, and we employed a converted open technique for biliary reconstruction. The other 11 patients had partial injury to the major bile duct, and we performed laparoscopic restoration; all 11 of these patients received endoscopic retrograde cholangiography (ERC) on the day after the operation and stenting for biliary decompression and drainage. No complications were identified and the duration of hospitalization in these patients was significantly shorter than in those who had the converted procedure. If intraoperative cholangiography is performed routinely, the presence and form of bile duct injury can be clearly identified, and the decision to restore the site of injury or to convert to the open technique for biliary reconstruction can be made immediately.

A novel conception for liver preservation at a temperature just above freezing point

BACKGROUND

It is generally accepted that 0 to 4 degreesC is a suitable temperature for organ preservation. The reason for this is based on the premise that at temperatures below 0 degreesC, intracellular ice is likely to form, with subsequent damage to cellular structures. However, it cannot be assumed that subzero temperatures will freeze the cell. In this study, we attempted to confirm the specific freezing point of rat liver and to preserve it at a temperature just above that point.

METHODS

Rat livers were stored for 24, 48, 72, and 96 h either at 4 degreesC (Group N) or at -0.8 degreesC (just above the temperature ascertained to be the specific freezing point of rat liver; Group H). After cold storage, the livers were perfused for 60 min using an isolated perfused liver model for assessment of liver function.

RESULTS

ATP and TAN (total adenine nucleotides) in reperfused liver tissues were significantly higher in Group H than in Group N for all preservation periods. ADP was significantly higher in Group H than in Group N for 24-, 72-, and 96-h preservation periods. Energy charge was significantly higher in Group H than in Group N for 24-, 48-, and 96-h preservation periods.

CONCLUSIONS

Regarding the content of ATP, ADP, and TAN and the adenylate energy charge, our results indicate that preservation at -0.8 degreesC is advantageous. This novel preservation technique seems to prolong the period that organs can be stored.

Ex vivo liver perfusion with arterial blood from a pig with ischemic liver failure

To simplify liver support using an ex vivo perfused liver, an isolated pig liver was perfused with arterial blood from the recipient pig while monitoring the metabolic capacity of the ex vivo perfused liver. It was possible to perfuse the isolated liver for more than 24 h using arterial blood from a pig with ischemic liver failure. The viability of the isolated liver during support from the liver failure pig was well maintained as evidenced by the high adenylate energy charge (0.815) and a constant ketone body ratio (KBR) of over 1.0 sampled from the hepatic vein. Oxygen consumption (mean, 29.0 microl/min/g of liver) and bile production (mean, 24.2 microl/h/g of liver) were significantly higher in the isolated liver connected to the liver failure pig than in the organ connected to the pig without liver failure (15.5 microl/min/g and 7.3 microl/h/g, respectively). These findings suggest that this liver support system has sufficient metabolic capacity to support a failed liver. Further studies may provide the experimental basis necessary for the clinical application of this device in treatment of patients with acute liver failure.

Hepatocyte growth factor stimulates synthesis of lipids and secretion of lipoproteins in rat hepatocytes

We have reported that infusion of recombinant human hepatocyte growth factor (rhHGF) stimulates liver regeneration after hepatectomy in cirrhotic rats and increases the level of serum lipids and secretion of very-low density lipoprotein (VLDL). Studies were now performed to determine whether rhHGF directly influences lipid synthesis and its secretion in cultured rat hepatocytes. Isolated cells were cultured in the presence or absence of rhHGF (20 ng/mL) for 2 days. During the first 12 hours, rhHGF transiently inhibited the release of lipids (triacylglycerol, total cholesterol, and phospholipids), but stimulated their releases with maximal levels achieved at 36 hours. [3H]-glycerol experiment with the transcriptional and translational inhibitors revealed that rhHGF stimulated de novo synthesis of lipids by affecting activities of lipid metabolic gene. [35S]-Methionine experiment also revealed de novo synthesis of apolipoprotein B by rhHGF. Furthermore, lipid analysis of lipoprotein fractions in the conditioned medium showed that rhHGF enhanced levels of triacylglycerol, total cholesterol, and phospholipids by 50% to 200% in both VLDL and low-density lipoproteins (LDL)/high-density lipoprotein (HDL). Genistein, a tyrosine kinase inhibitor, blocked the secretion of VLDL, as well as synthesis of lipids and apolipoprotein B stimulated by rhHGF. These results indicate that HGF likely stimulates lipid biosynthesis and lipoprotein secretion in hepatocytes through its tyrosine kinase-associated receptor, c-met, and accelerates the progress of cell maturation in liver regeneration.

Preoperative assessment for laparoscopic cholecystectomy: feasibility of using spiral computed tomography

OBJECTIVE

The authors investigated the preoperative feasibility of using spiral computed tomography (SCT) after intravenous infusion cholangiography (IVC-SCT) for laparoscopic cholecystectomy.

SUMMARY BACKGROUND DATA

In laparoscopic cholecystectomy, the aberrant or unusual anatomy of the bile duct and severe inflammation or adhesions around the gallbladder sometimes require a conversion to open surgery.

METHODS

Laparoscopic cholecystectomies (LC's) were attempted on 440 patients, and preoperative IVC-SCT also was attempted in all of these patients. Using this spiral scanning technique, the bile ducts, cystic duct, and gallbladder were assessed for contour abnormalities, relative position, and filling defects. Forty-seven patients were diagnosed with having stones in their common bile duct or common hepatic duct.

RESULTS

Three-hundred eighty-seven patients out of the 440 patients (88.0%) who were subjected to IVC-SCT had the length and course of their cystic duct successfully determined. Anomalous unions of the cystic duct were seen in 59 (15.2%) of 387 patients with respect to the operative findings, and 48 of 440 patients (10.9%) had severe adhesions to Calot's triangle and the surrounding tissues. In these 48 patients, 45 patients (94%) had a nonvisualized cystic duct on IVC-SCT. The preoperative assessment of the feasibility (dense adhesions obscuring Calot's triangle) of using IVC-SCT demonstrated that the sensitivity, specificity, and accuracy were 93%, 98%, and 94%, respectively. Five patients had to be converted to open surgery, and the overall morbidity rates for patients undergoing laparoscopic cholecystectomy was 0.9% (4 of 440).

CONCLUSIONS

The most important factor in assessing the feasibility of using laparoscopic cholecystectomy is not the nonvisualized gallbladder, but the nonvisualized cystic duct on IVC-SCT. IVC-SCT may be of benefit to those patients scheduled to undergo laparoscopic cholecystectomy.

Prolonged decreases in plasma nitrate levels at early postoperative phase after hepato-pancreato-biliary surgery

Nitric oxide (.NO) is known to influence circulatory, neural, immunologic, and metabolic alterations. To evaluate the clinical significance of .NO production under surgical stress, serial measurements of plasma nitrite plus nitrate levels were performed in 45 surgical patients. Group A included 19 patients who underwent major surgery with uneventful postoperative courses. Group B included 18 patients who underwent laparoscopic cholecystectomy. Group C included 8 patients whose surgery was complicated by intra-abdominal abscesses. Eight healthy volunteers served as controls. Plasma nitrate levels were determined with a redox chemiluminescence .NO analyzer and coincided with measurements made by high-performance liquid chromatography (r = 0.868, p < 0.0001, 58 samples). During laparotomy, arterial nitrate levels correlated well with peripheral, portal, and hepatic venous nitrate levels (r = 0.966, 0.938, and 0.949, respectively; p < 0.0001). A significant decrease in nitrate from preoperative levels in groups A (postoperative day (POD) 1 and 3; p < 0.0005) and B (POD 1, p < 0.0001) was observed; nitrate levels in group C did not decrease for 14 days after surgery. Plasma nitrate levels in groups A and B were significantly different (POD 1 through 6, p < 0.05) and at POD 3 were significantly lower in group A (p < 0.005). Plasma nitrate levels measured before and after fasting or food intake were not significantly different. These results suggest that surgical stress leads to a decrease in the end product of .NO in the whole body, and that the greater the surgical stress the longer the duration of decreased .NO production.

A simplified model of hypoxic injury in primary cultured rat hepatocytes

The Anaeropack system for cell culture, which was originally designed for the growth of anaerobic bacteria, was used to produce a hypoxic atmosphere for cultured hepatocytes. We measured changes in the oxygen and carbon dioxide concentrations and the atmospheric temperature in an airtight jar. We also measured changes in the pH of the medium during hypoxia to assess the accuracy of this system. Moreover, we used three durations (2, 3, and 4 h) of hypoxia and 8 h of reoxygenation in cultured rat hepatocytes, and then measured the lactate dehydrogenase (LDH), ketone body concentration (acetoacetate + beta-hydroxybutyrate), and the ketone body ratio (KBR: acetoacetate/beta-hydroxybutyrate) in the medium in order to assess the suitability of this system as a model for reperfusion following liver ischemia. The oxygen concentration dropped to 1% or less within 1 h. The concentration of carbon dioxide rose to about 5% at 30 min after the induction of the hypoxic conditions, and was maintained at this level for 5 h. No effect of the reaction heat produced by the oxygen absorbent in the jar was recognized. The extent of cell injury produced by changing the hypoxic parameters was satisfactorily reflected by the KBR, the ketone body concentration, and the LDH activity released into the medium. Because this model can duplicate the conditions of the hepatocytes during revascularization following ischemic liver, and the Anaeropack system for cell culture is easy to manipulate, it seems suitable for the experimental study of hypoxic injury and revascularization in vitro.

Spiral computed tomography scanning after intravenous infusion cholangiography for biliary duct anomalies

BACKGROUND

Iatrogenic injury of the bile duct during cholecystectomy represents a failure of surgical technique, especially for laparoscopic surgery. Knowledge of the patient's individual ductal anatomy and anomalies preoperatively would be helpful in avoiding such injuries. Therefore, we investigated the anatomy of the biliary duct and any anomalies using spiral computed tomography (SCT) scanning following intravenous infusion cholangiography (IVC-SCT).

MATERIALS

Laparoscopic cholecystectomies (LC) were attempted on 437 patients at the Kansai Medical University. Preoperative IVC-SCT and laparoscopic cholangiography were attempted in all of the patients.

RESULTS

An overall anomalous union of the cystic duct was seen in 71 (16.2%) out of the 437 patients subjected to IVC-SCT. The following anomalies were observed: right hepatic duct entry in 7 cases (1.6%), parallel low entry in 17 cases (3.9%), posterior spiral entry in 35 cases (8.0%), anterior spiral entry in 7 cases (1.6%), and accessory duct entry in 5 cases (1.1%). The success rate for the LC was 99.5% (435/437). Three patients were switched to open surgery owing to advanced gallbladder cancer and severe adhesions. The success rate for the laparoscopic cholangiography was 97.2% (423 of 435). Intraoperative right hepatic duct injury occurred in only 1 patient with a bile duct anomaly, and it was repaired with laparoscopic T-tube drainage.

CONCLUSIONS

The preoperative examination of the biliary tract by IVC-SCT was technically simple, less invasive, and may helpful in avoiding damage to the bile duct, especially in patients with biliary duct anomalies.

Stimulation of liver regeneration and function after partial hepatectomy in cirrhotic rats by continuous infusion of recombinant human hepatocyte growth factor

BACKGROUND/AIMS

Radical resection is accepted as one of the most curative treatments for hepatocellular carcinoma. However, most patients have coexisting cirrhosis and their liver function is usually impaired. It is therefore important to stimulate the regeneration and function of the remnant cirrhotic liver after hepatectomy. Hepatocyte growth factor is a potent mitogen that has been suggested to play a crucial role in liver regeneration.

METHODS

In this study, we performed 45% hepatectomy in rats with cirrhosis induced by thioacetamide, and administered recombinant human hepatocyte growth factor (rhHGF) with dextran sulfate by continuous infusion into the jugular vein with an infusion pump.

RESULTS

rhHGF stimulated an increase in the wet weight of the remnant liver compared with untreated control rats. The proliferating cell nuclear antigen labeling index showed that this increase resulted from the stimulation of DNA synthesis. Serum levels of liver enzymes increased after hepatectomy, but returned to the prehepatectomy level more rapidly in rhHGF-treated rats than in controls. rhHGF increased hepatic protein synthesis above prehepatectomy levels and also markedly increased the serum levels of hepatic lipid metabolites.

CONCLUSIONS

These results demonstrate that continuous intravenous infusion of rhHGF enhances the growth and function of the remnant liver in rats with cirrhosis after partial hepatectomy. Therefore, rhHGF may be useful after hepatic resection in patients with cirrhosis.

Prophylactic laparoscopic ovarian ablation for premenopausal breast cancer: medical and economic efficacy

Worldwide analysis showed a highly significant reduction in the annual rates both of recurrence and of death produced by ovarian ablation. We examined the safety, efficacy, and cost-effectiveness of prophylactic laparoscopic oophorectomy for premenopausal breast cancer. Prophylactic laparoscopic oophorectomy was attempted in 15 selected premenopausal patients with breast cancer. After mastectomy, these patients had laparoscopic ovarian ablation as treatment for breast carcinoma with positive estrogen receptors. To evaluate the economic impact of laparoscopic oophorectomy, comparisons were made between patients treated laparoscopically and those treated with conventional surgery, chemotherapy, and hormonal therapy. The average time required for laparoscopic bilateral oophorectomy was 44 min. Oral intake was resumed the next morning, and the patients were discharged 3 days after surgery. No limitation on physical activity and no complications were required during postoperative days. There was no reduction in the overall costs of laparoscopic surgery and conventional surgery in Japan. The cost of one year's supply of tamoxifen was equivalent to the overall cost of surgical oophorectomy. From medical and economic viewpoints, we conclude that laparoscopic ovarian ablation should be considered an alternative to adjuvant chemotherapy in premenopausal women.

Preoperative determination of the surgical procedure for hepatectomy using technetium-99m-galactosyl human serum albumin (99mTc-GSA) liver scintigraphy

Technetium-99m-diethylenetriaminepentaacetic acidgalactosyl human serum albumin (Tc-GSA) is a new liver scintigraphy agent which binds to the asialoglycoprotein receptors. We evaluated the preoperative assessment for hepatectomy using Tc-GSA liver scintigraphy. Ninety patients with hepatocellular carcinoma were admitted for elective hepatectomy. Tc-GSA scintigraphy was conducted after the intravenous injection of Tc-GSA, and maximal removal rate of Tc-GSA (GSA-Rmax) was calculated using a radiopharmacokinetic model. Measurement of GSA-Rmax, conventional liver function, and 15-minute retention rate of indocyanine green (ICGR15) was carried out preoperatively. The relationships between liver functions, histological activity index (HAI), ICGR15, and GSA-Rmax values were estimated. A significant correlation was obtained between GSA-Rmax and ICGR15 (r = .534, P < .0001). Preoperative discrepancies between GSA-Rmax and ICGR15 values were seen in 15 patients. In these cases, the GSA-Rmax values correlated well with the total HAI scores (r = .595, P < .02), but no significant correlation was seen between the ICGR15 and HAI scores. Two patients died of postoperative liver failure within 2 months of the operation. These two patients were found to have severe discrepancies between their preoperative GSA-Rmax and ICGR15 values. We concluded that GSA-Rmax might be useful for selecting candidates for hepatectomy and that extended hepatectomies (di- and tri-segmentectomy) are high-risk surgical procedures in the case of low GSA-Rmax scores (below 0.35).

Assessing the eligibility for liver transplantation of patients with fulminant hepatitis

The spleen to liver volume (S/L) ratio of 13 patients with fulminant hepatitis was determined using X-ray computed tomography (CT), and the correlation between S/L ratio and prognosis was evaluated. The S/L ratio of 6 patients who died was greater than 0.16, whereas that of the remaining 7 patients who survived was less than 0.15. These findings suggest that determining the S/L ratio using CT may be useful for assessing the eligibility of patients with fulminant hepatitis for liver transplantation.

Clinical evaluation of closed suction drainage following hepatectomy

A prospective randomized study on 186 patients was conducted to determine the influence of closed suction drainage (n = 102) versus open drainage (n = 84) on the incidence of postoperative complications after elective hepatic resection. The patients were randomly allocated between the two groups. A total of 60 complications occurred in 31 of the 84 patients (36.9%) given open drainage, while 24 complications occurred in 15 of the 102 patients (14.7%) given closed suction drainage. The incidence of pleural effusion, postoperative ascites, and infected subphrenic collections was significantly lower in the closed suction drainage group than in the open drainage group, at 31% vs 16% (P < 0.05), 19% vs 3% (P < 0.01), and 17% vs 5% (P < 0.05) respectively. However, both groups showed similar rates of subphrenic hematoma and bile collection. These findings indicate that closed suction drainage significantly reduces the incidence of postoperative complications after elective hepatic resection.

Gallbladder cancer with a low junction of the cystic duct or an anomalous pancreaticobiliary junction

OBJECTIVE

To evaluate conditions similar to those of carcinogenesis of the gallbladder between the gallbladder with a low junction of the cystic duct (LJCD) and an anomalous pancreaticobiliary junction (APBJ).

DESIGN

Retrospective and clinicopathological analysis of patients with gallbladder carcinoma.

SETTING

First Department of Surgery, Kansai Medical University.

PATIENTS

Examination of 47 patients (7 men and 40 women; average age: 67.8 years) with gallbladder carcinoma revealed 7 patients (14.9%; 1 man and 6 women; average age: 67.8 years) with LJCD and 6 patients (12.8%; 6 women; average age: 60.3 years) with APBJ.

METHODS

Clinical findings in both groups were compared with those of the 34 patients who remained after exclusion of the data of the above 7 patients with LJCD and 6 patients with APBJ. The data of the three groups were examined by the chi 2 test at the 5% level of significance.

RESULTS

Most of the gallbladder cancer patients with LJCD or APBJ had gallstones. The biliary amylase levels determined in the gallbladder of patients with LJCD or APBJ were remarkably high.

CONCLUSION

The results indicate that patients with LJCD or APBJ are more likely to develop carcinoma of the gallbladder. The factors responsible for carcinogenesis may be alteration of the bile content due to reflux of pancreatic enzymes through the LJCD or APBJ, and mechanical irritation due to gallstones. Therefore, these pathological conditions in patients with LJCD are similar to those experienced in patients with APBJ.

Inflammatory pseudotumor of the liver: report of a case and review of the literature

Only 56 cases of inflammatory pseudotumor of the liver have been reported in the world literature since its first documentation in 1953. We report herein the case of a 68-year-old man incidentally found to have a lesion in the right lobe of the liver which closely resembled a neoplasm on imaging studies. Thus, partial hepatic resection was performed and histological examination of the resected specimen revealed a diagnosis of inflammatory pseudotumor. Surgical resection is the preferred treatment for inflammatory pseudotumor of the liver, especially in patients for whom a definite histologic diagnosis cannot be made preoperatively or by intraoperative frozen sections. In fact, most of the patients reported in the literature recovered uneventfully after local resection without any postoperative complications, as did our patient.

Hepatocyte volume as an indicator of hepatic functional reserve in cirrhotic patients with liver tumours

Using computed tomography (CT), measurements of whole liver volume have been used for the assessment of pre-operative functional reserve in cirrhotics. However, measurements of hepatocyte volume, which exclude stromal fibrous tissue, are considered to more directly reflect hepatic functional reserve. We investigated the relationship between total hepatocyte volume and each of the parameters of conventional liver function. Indocyanine green (ICG) tests and blood analyses for the assessment of liver function were performed prior to surgery in cirrhotic patients with liver tumours. Pre-operative liver volume was determined by integrating images of each liver area obtained by CT. Liver area was measured by an image processing program that traced the profile of the liver image while excluding the tumorous area. Sections of normal tissue stained by the haematoxylin-eosin method, were obtained from the resected liver. Using these sections, a hepatocyte area: whole tissue area ratio was calculated using the image processing program, by tracing the profiles of the hepatocyte nodules. The total volume of hepatocytes was then calculated by multiplying the liver volume by this ratio. The hepatocyte volume per unit bodyweight was significantly correlated with ICG tests and with many other parameters of normal liver function. However, the liver volume per unit bodyweight was correlated only with the plasma ICG disappearance rate and with the blood platelet count. These observations suggest that the functional reserve of the cirrhotic liver is assessed more precisely by hepatocyte volume than by liver volume.

[Computed tomography with continuous transport and continuous scanner rotation for laparoscopic cholecystectomy]

We investigated the 58 cases of cholecystolithiasis including 8 cases of choledocholithiasis treated with laparoscopic cholecystectomy. All patients received spiral CT scanning with drip infusion cholangiography (DIC-SCT), and 1.6 patients received endoscopic retrograde cholangiography (ERC), and the detection rates of the gallbladder, the bile duct and the cystic duct were compared. The gallbladder could be seen in 86.2% of cases with DIC-SCT and in 63.8% of cases with conventional DIC. The junction between the cystic duct and the common bile duct could be seen in 18 of 58 cases with DIC and in 49 of 58 cases with DIC-SCT. The DIC-SCT showed significantly superior anatomical details compared with images with conventional DIC. A comparison of DIC, ERC and DIC-SCT revealed that the junction between the cystic duct and the common bile duct could be identified in 14 of 16 cases undergoing ERC, in 13 of 16 cases receiving DIC-SCT and in 4 of 16 cases receiving DIC. Significant differences were noted among DIC-SCT, ERC and conventional DIC. We concluded that DIC-SCT is easy, non-invasive and useful for the preoperative assessment of laparoscopic cholecystectomy and also helpful for avoiding damage to the bile duct.

Use of technetium 99m diethylenetriamine-pentaacetic acid-galactosyl-human serum albumin liver scintigraphy in the evaluation of preoperative and postoperative hepatic functional reserve for hepatectomy

BACKGROUND

Technetium 99m diethylenetriaminepentaacetic acid-galactosyl-human serum albumin (99mTc-GSA) is a new liver scintigraphy agent that binds to the asialoglycoprotein receptors. We evaluated the clinical use of 99mTc-GSA for the perioperative assessment of hepatectomy.

METHODS

Thirty-six patients with hepatocellular carcinoma were admitted for elective hepatectomy. 99mTc-GSA scintigraphy was obtained after the intravenous injection of 99mTc-GSA, and a modified receptor index (MRI) was calculated. 99mTc-GSA scintigraphy, conventional liver function, the plasma disappearance rate, and the 15-minute retention rate of indocyanine green (ICGR15) were carried out before operation and every 1 to 3 months after operation. The relationships between several systemic hemodynamic parameters, histologic activity index (HAI), plasma disappearance rate, and ICGR15 or MRI values were estimated.

RESULTS

A significant correlation was obtained between the MRI and ICGR15 (r = 0.6231, p < 0.001). Plasma disappearance rates correlated well with systolic volume and left cardiac work, whereas MRI values did not correlate with these systemic hemodynamics. Preoperative discrepancies between the values of MRI and ICGR15 were seen in eight cases. In these cases the MRI values correlated well with HAI scores (p < 0.05) but there was no significant correlation between ICGR15 values and the HAI scores.

CONCLUSIONS

These results suggested the use of 99mTc-GSA scintigraphy as a easy and reliable method for determining liver functional reserve.

Three-dimensional reconstruction of the biliary tract using spiral computed tomography

Spiral computed tomography (SCT) is a recently introduced technique which enables scanning of one large volume with no interscan intervals. Three-dimensional reconstruction using this technique is emerging as an effective means of identifying complex anatomical relationships. Ninety-two patients with cholecystolithiasis including ten with choledocholithiasis were investigated. All underwent SCT after oral and intravenous infusion cholangiography (IVC-SCT) and 22 were also examined by endoscopic retrograde cholangiography (ERC). IVC-SCT showed significantly more anatomical detail than conventional intravenous infusion cholangiography (IVC). The junction between the cystic duct and the common bile duct could be identified before surgery in 19 of 22 patients undergoing ERC, in 18 of 22 receiving IVC-SCT and in five of 22 undergoing IVC. Significant differences were noted between IVC-SCT, ERC and conventional IVC. Three-dimensional surface reconstruction of the biliary tract is useful in the evaluation of anatomical relationships between the cystic duct and the common bile duct (clearly seen in 86 per cent of cases). Three-dimensional reconstruction using SCT scanning is useful for anatomical assessment before laparoscopic cholecystectomy.

Effect of hepatocyte volume on energy status in the cirrhotic rat liver

To evaluate the effect of reduced hepatocyte volume on liver energy status, the relationship between the morphologically quantified hepatocyte volume and biochemical parameters, and the difference in nuclear density between the parenchyma and stroma were assessed in rat livers with thioacetamide-induced cirrhosis. The ratio of hepatocytes to whole liver tissue, defined as the 'hepatocyte area ratio', and the nuclear densities of the parenchyma and stroma were calculated microscopically with an image analysing system. Adenine nucleotide, protein and DNA contents, and the ornithine carbamoyltransferase activity in the liver were assayed. In the cirrhotic group, adenine nucleotide content, protein content and ornithine carbamoyltransferase activity were positively correlated with the hepatocyte area ratio, whereas DNA content was negatively correlated with this ratio. The adenylate energy charge of the cirrhotic liver was maintained at a constant level regardless of the ratio. Adenine nucleotide content, protein content and ornithine carbamoyltransferase activity per fractional 'hepatocyte area ratio' in cirrhotic livers were significantly lower than in control livers. The nuclear density of the stroma was significantly greater than that of the parenchyma. These results suggest that the lowered energy status in the cirrhotic liver is not caused by reduced hepatocyte volume but rather by impaired hepatocyte metabolism. In addition, the morphological measurement with an image analysing system was found to be useful for evaluating the effects of decreased hepatocyte volume on biochemical derangements in cirrhotic tissue.

Prevention of pleural effusion after hepatectomy using fibrin sealant

Retention of pleural effusion after hepatectomy is an important complication that may affect the postoperative course. However, there are few reports on its pathogenesis or preventive measures. We evaluated the mechanism of the development of this complication and preventive measures against it. During the past 4-year period, hepatectomy was performed in 77 patients, of whom 64 underwent liver mobilization by transecting the hepatic ligaments. A fibrin sealant was sprayed on the cut surface of the hepatic ligaments in randomly selected 25 of the 64 patients to determine whether this application can prevent postoperative retention of pleural effusion. Post-operative pleural effusion was not observed in any patient treated by fibrin sealant spraying but was observed in 13 (30%) of the other 39 patients treated with this sealant (p < 0.05). In addition, none of the 23 patients in whom the liver was not mobilized during hepatectomy showed postoperative pleural effusion. These results suggest that severance of the hepatic ligaments is a major cause of pleural effusion, and application of a fibrin sealant to the undersurface of the diaphragm around the insertion of the liver ligaments is useful for preventing this complication.

Response of fibronectin to liver regeneration after hepatectomy

The relationship between plasma fibronectin concentration and the regenerative process in liver remnants after hepatectomy was studied in 12 patients and in male Sprague-Dawley rats with and without cirrhosis. Plasma fibronectin levels were reduced immediately after hepatectomy in humans and rats. Patients and rats without cirrhosis displayed preoperative fibronectin levels within 1 mo and 1 wk, respectively, but low fibronectin levels persisted longer in those with cirrhosis. Plasma fibronectin levels correlated well with the degree of hepatic regeneration in the patients with cirrhosis (r = 0.4227; p less than 0.05) and without cirrhosis (r = 0.8148; p less than 0.001), and also with the percentage of change in liver weight during regeneration in the rat with thioacetamide-induced cirrhosis (r = 0.4905; p less than 0.01) or in the rat without cirrhosis (r = 0.6422; p less than 0.001). These results suggest that plasma fibronectin is a useful marker for the detection of regenerating liver.

Effect of administration of fibronectin or aprotinin on liver regeneration after experimental hepatectomy

Following 70% hepatectomy, male Sprague-Dawley strain rats were given purified human plasma fibronectin and/or aprotinin intraperitoneally after hepatectomy and were divided into 4 groups: Group FA (40 mg/kg of FN and 25,000 KIU/kg of aprotinin), Group F (40 mg/kg of fibronectin), Group A (25,000 KIU/kg of aprotinin), and Group C which served as a control. The liver regeneration rate 72 hours after hepatectomy in Groups FA and F, and the plasma FN levels at 24 and 72 hours following hepatectomy in groups with FN, were significantly higher than that of the control group. The incorporation of 3H-thymidine into DNA and the phagocytic index of the reticuloendothelial system at 24 hours in Groups FA and F, and the mitotic index at 72 hours after hepatectomy in Group FA were significantly increased as compared to the control. But the supplementation of 20 mg/kg of indomethacin to the 4 groups resulted in significant suppression of 3H-thymidine uptake 24 hours after hepatectomy. Moreover, plasma fibronectin levels in rats correlated well with the phagocytic index and DNA synthesis 24 hours following partial hepatectomy. These results suggest that fibronectin may act as an activator of the reticuloendothelial system, related to prostaglandins, in the process of liver regeneration.