Increased ghrelin signaling prolongs survival in mouse models of human aging through activation of sirtuin1

Caloric restriction (CR) is known to retard aging and delay functional decline as well as the onset of diseases in most organisms. Ghrelin is secreted from the stomach in response to CR and regulates energy metabolism. We hypothesized that in CR ghrelin has a role in protecting aging-related diseases. We examined the physiological mechanisms underlying the ghrelin system during the aging process in three mouse strains with different genetic and biochemical backgrounds as animal models of accelerated or normal human aging. The elevated plasma ghrelin concentration was observed in both klotho-deficient and senescence-accelerated mouse prone/8 (SAMP8) mice. Ghrelin treatment failed to stimulate appetite and prolong survival in klotho-deficient mice, suggesting the existence of ghrelin resistance in the process of aging. However, ghrelin antagonist hastened death and ghrelin signaling potentiators rikkunshito and atractylodin ameliorated several age-related diseases with decreased microglial activation in the brain and prolonged survival in klotho-deficient, SAMP8 and aged ICR mice. In vitro experiments, the elevated sirtuin1 (SIRT1) activity and protein expression through the cAMP-CREB pathway was observed after ghrelin and ghrelin potentiator treatment in ghrelin receptor 1a-expressing cells and human umbilical vein endothelial cells. Furthermore, rikkunshito increased hypothalamic SIRT1 activity and SIRT1 protein expression of the heart in the all three mouse models of aging. Pericarditis, myocardial calcification and atrophy of myocardial and muscle fiber were improved by treatment with rikkunshito. Ghrelin signaling may represent one of the mechanisms activated by CR, and potentiating ghrelin signaling may be useful to extend health and lifespan.

Validation study of the Japanese version of the Faecal Incontinence Quality of Life Scale

AIM

The aim of the present study was to conduct a psychometric validation of the Japanese version of the FIQL (JFIQL).

METHOD

A retrospective analysis of data from the JFIQL was conducted. Wexner scores and Faecal Incontinence Severity Index (FISI) scores were collected prospectively in patients with faecal incontinence who visited our centre between 2008 and 2009. For convergent validity, the JFIQL scores were compared with stages on the Wexner scale for lifestyle alteration. To evaluate reliability, Cronbach's alpha was calculated for internal consistency, whereas a test-retest study was performed to evaluate reproducibility. In assessing responsiveness, JFIQL scores before and after treatments were compared in patients whose FISI scores decreased by ≥ 50%.

RESULTS

Convergent validity and internal consistency were determined in 70 patients (49 women; median age 68.5 years). The JFIQL scores were significantly associated with lifestyle alteration stages on the Wexner scale, demonstrating convergent validity in all four domains and the generic score. Cronbach's alpha was > 0.7 for generic scores and all domains except Embarrassment. The intraclass correlations for the 27 patients available for the test-retest study were > 0.7 for generic scores and all domains except Embarrassment. The median JFIQL score improved significantly after treatment in the 23 patients whose FISI scores decreased ≥ 50%, indicating good responsiveness in all four domains and the generic score.

CONCLUSION

The JFIQL has been validated and is now ready for use in evaluating the symptom-specific quality of life in Japanese patients with faecal incontinence.

Risk factors and predictors for surgical site infection after hepatic resection

Strict control of blood glucose levels with insulin in a surgical intensive care unit reduces postoperative morbidity and mortality. The aim of this study was to identify risk factors and the predictors for the prevention of surgical site infection (SSI) in a consecutive series of hepatectomised cases in a single institution. The association between SSI and various clinical parameters was investigated in 152 patients who underwent hepatic resection at Kochi Medical School from January 2000 through March 2007. The incidence of SSI in these patients was 14.5%. Multivariate analysis identified four independent parameters correlating with the occurrence of SSI: (i) body mass index >23.6 kg/m(2); (ii) estimated blood volume loss >810 mL; (iii) presence of postoperative bile leakage of organ/space SSI; and (iv) use of the sliding scale method for postoperative glucose control. There was no observed SSI after liver resection in the group whose postoperative blood glucose levels were controlled by an artificial pancreas. This study reveals that lack of postoperative glycaemic control is associated with a significantly higher incidence of postoperative infectious complications and longer hospitalisation. Obesity and the level of intraoperative estimated blood loss and bile leakage after hepatic resection are also risk factors with predictive value for SSI. Artificial pancreas is a safe and beneficial device to perform postoperative strict glycaemic control without hypoglycaemia for patients who undergo hepatic resection for liver diseases.

Accuracy and reliability of continuous blood glucose monitor in post-surgical patients

BACKGROUND

The STG-22 is the only continuous blood glucose monitoring system currently available. The aim of this study is to determine the accuracy and reliability of the STG-22 for continuously monitoring blood glucose level in post-surgical patients.

METHODS

Fifty patients scheduled for routine surgery were studied in surgical intensive care unit (ICU) of a university hospital. After admission to the ICU, the STG-22 was connected to the patients. An attending physician obtained blood samples from a radial arterial catheter. Blood glucose level was measured using the ABL800FLEX immediately after blood collection at 0, 4, 8, and 16 h post-admission to the ICU (total of 200 blood glucose values).

RESULTS

The correlation coefficient (R2) was 0.96. In the Clarke error grid, 100% of the paired measurements were in the clinically acceptable zone A and B. The Bland and Altman analysis showed that bias+/-limits of agreement (percent error) were 0.04(0.7)+/-0.35(6.3) mmol (mg/dl) (7%), -0.11(-2)+/-1.22(22) (15%) and -0.33(-6)+/-1.28(23) (10%) in hypoglycemia (<70(3.89) mmol (mg/dl), normoglycemia (3.89(70)-10(180) mmol (mg/dl), and hyperglycemia (>10(180) mmol (mg/dl), respectively.

CONCLUSIONS

The STG-22 can be used for measuring blood glucose level continuously and measurement results are consistent with intermittent measurement (percentage error within 15%). Therefore, the STG-22 is a useful device for monitoring in blood glucose level in the ICU for 16 h.

Can sedation reduce the cardiac stress during gastrointestinal endoscopy? A study with non-invasive automated cardiac flow measurement by color Doppler echocardiography

BACKGROUND

Upper gastrointestinal endoscopy (UGIE) may cause some cardiac stress. The effect of sedation on hemodynamics during UGIE has not been fully studied, and therefore the aim of this study was to clarify whether or not sedation can reduce cardiac stress dufing UGIE.

METHODS

Eight normal male volunteers undergoing UGIE with sedation (0.1 mg/kg of midazolam) and without it (two endoscopies per volunteer in random order) were monitored throughout the procedure by means of electrocardiogram, blood pressure and peripheral oxygen saturation (SpO2). Cardiac output was measured at six points before, during and after endoscopy from automated cardiac flow measurement by color Doppler echocardiography. Serum norepinephrine, epinephrine, dopamine and ACTH concentrations were measured before and after the examination.

RESULTS

No significant differences in heart rate, systolic blood pressure, rate-pressure product, cardiac output and left ventricular work index were observed between the sedated and non-sedated groups. SpO2 hardly changed during endoscopy in the non-sedated group, but decreased slightly in the sedated group (P = 0.075). Although all serum catecholamine concentration changes were within normal limits in both groups, after endoscopy only epinephrine concentration was significantly lower in the sedated group than in the non-sedated group (P = 0.0027).

CONCLUSIONS

Conscious sedation with midazolam does not reduce the cardiac stress during UGIE.

Coexpression of vascular endothelial growth factor and p53 protein in squamous cell carcinoma of the esophagus

OBJECTIVE

p53 plays a role in tumor angiogenesis, and vascular endothelial growth factor (VEGF) plays a key role in tumor angiogenesis. The aim of the present study was to clarify how expression of p53 protein participates in angiogenesis, and whether the coexpression of VEGF and p53 protein has a significance for angiogenesis and the clinicopathological features in esophageal squamous cell carcinoma (SCC).

METHODS

Tissues samples were taken from 60 patients with esophageal SCC after surgery. The expression of VEGF and p53 protein in these SCC was examined immunohistochemically. Microvessel density (MVD) was determined by counting microvessels in tumor sections stained for Factor VIII-related antigen. Ki-67 labeling index (LI) was calculated, based on Ki-67 antigen immunostaining, as a proliferative marker. Apoptotic index (AI) was calculated, based on the terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate biotin nick end labeling, to evaluate apoptosis.

RESULTS

VEGF expression was observed in 58.3%, and p53 protein expression was observed in 61.7% of the 60 patients. VEGF and p53 protein were significantly coexpressed in 26 (43.4%). Histological venous invasion (p < 0.01) and distant metastasis (p < 0.05) were significantly correlated with p53 protein expression. The two parameters were more frequently observed in the SCC with VEGF/p53 coexpression than in those without the coexpression. The MVD and Ki-67 LI were significantly higher (p < 0.01 and p < 0.001), and the AI was significantly lower (p < 0.001) in the SCC with p53 protein expression than in the SCC without it. The MVD and Ki-67 LI were higher, and the AI was lower in the SCC with VEGF/p53 coexpression than in those without the coexpression. The 5-yr survival rate in patients with the coexpression was poorer than in the other patients.

CONCLUSION

These results suggest that mutant p53 expression is associated with angiogenesis and distant metastasis in esophageal SCC, and that the coexpression of p53 and VEGF may play an important role in angiogenesis, and have important clinical significance.

Hepatic resection for large hepatocellular carcinoma

BACKGROUND

Long-term survival and prognostic factors after hepatic resection for large hepatocellular carcinoma (HCC) remain to be proved.

METHODS

The surgical outcome in 133 consecutive patients with HCC in diameter of > or = 5 cm (large HCC; L group) undergoing hepatic resection was retrospectively clarified and compared with that of 253 patients with HCC in diameter of < 5 cm (small HCC; S group). Postresection prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model.

RESULTS

The disease-free 3- and 5-year survival rates between L group and S group were 26% versus 42% and 20% versus 25%, respectively (P = 0.0032). The overall 3- and 5-year survival rates between L group and S group were 38% versus 67% and 28% versus 47%, respectively (P < 0.0001). Multivariate analysis revealed that large amount of intraoperative blood transfusion was an independently significant factor of poor disease-free and overall survivals.

CONCLUSIONS

Long-term survival in patients with large HCC remains unsatisfactory compared with that in patients with non-large HCC. Restriction of intraoperative blood transfusion may play an important role in the improvement of survival and recurrence in such patients.

Prognostic factors after hepatic resection for hepatocellular carcinoma with hepatitis C viral infection: univariate and multivariate analysis

OBJECTIVES

Although the incidence of hepatocellular carcinoma (HCC) with hepatitis C virus (HCV) infection is higher than in patients with hepatitis B virus (HBV)-related HCC in Japan, the long-term prognosis and prognostic factors of HCV-related HCC after hepatic resection are poorly understood.

METHODS

The surgical outcome of HCV-related HCC in 172 consecutive patients who underwent hepatic resection between 1989 and 1997 was retrospectively clarified. Postresection prognostic factors were evaluated by univariate and multivariate analysis using Cox's proportional hazards model.

RESULTS

The overall incidence of postoperative complications was 23.2%, and 11 patients among that group had hospital deaths (6.4%) including 9 (5.2%) operative deaths. The mean and median overall survivals including hospital death after surgery were 41 months and 33 months, respectively. The 3-, 5-, and 7-yr overall survival rates after hepatic resection were 63%, 52%, and 47%, respectively. The 3-, 5-, and 7-yr disease-free survival rates after hepatic resection were 33%, 20%, and 15%, respectively. Multivariate analysis revealed that serum alpha-fetoprotein (AFP) of > or = 1000 ng/ml and the presence of vascular invasion were independent unfavorable prognostic factors affecting overall survival and that AFP of > or = 1000 ng/ml was an independently significant factor of poor disease-free survival.

CONCLUSIONS

We found the postresection survival of patients with HCV-related HCC should be stratified by the high value of AFP and the presence of vascular invasion. AFP may be the most powerful predictor of the long-term prognosis and recurrence in such patients.

A squamous cell carcinoma of the gastric cardia showing submucosal progression

We report a case of squamous cell carcinoma (SCC) of the gastric cardia showing submucosal progression with direct invasion of the liver. A 71-year-old man was admitted with dysphagia. Esophagogastroscopy showed a protruding tumor covered with normal gastric mucosa in the anterior wall of the gastric cardia, although no abnormal findings were detected in the esophagus, including the esophagogastric junction. Serum SCC-related antigen level was elevated (6.6 ng/ml; normal level, less than 2.5 ng/ml). Endoscopic biopsy specimens taken from this tumor did not show malignant cells. Based on these findings, the preoperative diagnosis was a submucosal tumor of the stomach. Laparotomy was done; however, the tumor was not resected because it had direct invasion to the left lateral segment of the liver and adjacent tissues. As the tumor showed continuous bleeding from the stomach after surgery, total gastrectomy, combined with transhiatal lower esophagectomy, left lateral segmentectomy of the liver, splenectomy, and distal pancreatectomy was performed. Because histologic findings showed poorly or moderately differentiated SCC with direct invasion of the liver, the final diagnosis was SCC of the gastric cardia showing submucosal progression with hepatic invasion. Such a case of SCC of the gastric cardia showing submucosal progression is rare, and accurate preoperative diagnosis was very difficult. However, it may be important to consider SCC of the gastric cardia in such a situation.

Cavernous hemangioma of the liver with giant cyst formation: degeneration by apoptosis?

Cavernous hemangioma of the liver with cyst formation is a very rare condition. A case of cavernous hemangioma of the liver with unilocular giant cyst formation undergoing surgical removal is reported. Notably, the patient also had Budd-Chiari syndrome with an obstructing lesion in the inferior vena cava. The cystic degeneration of the hemangioma implied a relationship with apoptosis. This is the first reported case of Budd-Chiari syndrome caused by advanced cystic degeneration of hepatic cavernous hemangioma.

Co-occurrence of mucoepidermoid carcinoma and squamous cell carcinoma of the esophagus: report of a case

A case of co-occurrence of a mucoepidermoid carcinoma (MEC) and a squamous cell carcinoma (SCC) in the esophagus is described. The present patient was a 61-year-old man who underwent a curative esophagectomy with a regional lymph node dissection for a MEC in the lower esophagus and a SCC near the esophagogastric junction. The two lesions were endoscopically and histologically divided by a normal esophageal mucosa. The MEC of the esophagus consisted of SCC cells and signet-ring cells, and a mucin product and carcinoembryonic antigen, which were found at high levels in the blood serum before surgery, were detected histochemically in the signet-ring cells. The follow-up survey of the patients with esophageal MEC previously reported in Japan showed that most of the patients died of either local recurrence or widespread metastasis after treatment; the overall 5-year survival rate was 24.4% in the total 25 cases, and 27.7% in the 22 resected cases. However, 6 patients who died of therapeutic complications were included among these patients; furthermore, the 5-year survival rate after surgery was 29.2% in the patients treated over the last decade (1989-1998). We expect that the clinical outcome of patients treated for esophageal MEC will therefore improve in the future.

Ulcer in the gastric tube for esophageal replacement: a comparison of 12 esophageal cancer patients with or without postoperative radiotherapy

BACKGROUND AND AIMS

Ulcer in the gastric tube for esophageal replacement, which was caused by peptic factors or postoperative radiotherapy (Rx), are occasionally reported. The aim of this study was to clarify the clinicopathologic features of the ulcers in the gastric tube.

METHODS

In 62 patients with a reconstructed gastric tube, after esophagectomy for esophageal cancer, esophagogastroduodenoscopy was performed. Ulcers of the gastric tube were detected in 12 patients: six with postoperative Rx and six without Rx. The 12 patients with gastric tube ulcers (GU-group) were reviewed and compared to the remaining 50 patients without ulcers of the gastric tube (Control-group). Clinicopathologic features of gastric tube ulcers were compared between the patients with and without Rx.

RESULTS

There was no difference in any parameter between the patients of the GU- and Control-groups. Comparing the patients of the GU-group with and without Rx, the ulcers of the gastric tube in the patients without Rx were frequently located in the lower part of the gastric tube (P = 0.067), detected in a later period after surgery (P = 0.055), associated with cervical esophagitis (P = 0.03), and less associated with gastritis (P = 0.03). In three patients of the GU-group without Rx, Helicobacter pylori was detected in the gastric tube. Two of the three patients had a history of peptic ulcers before surgery, and had recurrence of the gastric tube ulcers.

CONCLUSIONS

Gastric tube ulcers without postoperative Rx may have different characteristics compared to those induced by Rx.

Portal vein thrombosis associated with hilar bile duct carcinoma and liver abscess

As most portal vein occlusion in hilar bile duct carcinoma is caused by tumor invasion to the portal vein, other mechanisms of its occlusion are very rare. We report the case of a 69-year-old man who underwent surgical resection for an advanced hilar bile duct carcinoma associated with unusual portal vein occlusion. Preoperative diagnosis was advanced hilar bile duct carcinoma with liver abscess and right portal vein occlusion due to tumor invasion. Extended right hepatectomy combined with resection of caudate lobe was performed. Intraoperatively, tumor invasion to the portal vein was not evident and resected margin of the right portal vein showed thrombosis and no evidence of malignancy histologically. To our knowledge, this is the first reported case of a patient with a combination of portal vein thrombosis and liver abscess in hilar bile duct carcinoma. Although portal vein occlusion due to thrombosis is an unusual complication in hilar bile duct carcinoma, the presence of liver abscess may be a useful diagnostic implication of this occlusion.

Hepatic resection for hepatocellular carcinoma in the elderly

BACKGROUND

Although the number of elderly people undergoing surgery for hepatocellular carcinoma (HCC) has increased because of the prolonged life expectancy rate, potential benefits of hepatectomy for elderly patients with HCC have not been fully delineated.

STUDY DESIGN

Using medical records, surgical outcomes of HCC in 103 patients 70 years of age or older undergoing hepatic resection (older group) were clarified and compared with those of 283 patients younger than 70 years of age (younger group) in this retrospective study. Postresection prognostic factors were evaluated by multivariate analysis using Cox's proportional hazards model.

RESULTS

There were no significant differences in postoperative complication, operative mortality, and overall hospital death rates between the two groups. Overall 3- and 5-year survival rates for the older group and the younger group were 51.0% versus 55.2%, and 42.2% versus 40.0%, respectively (p = 0.95). Disease-free 3- and 5-year survival rates for the older group and the younger group were 35.2% versus 37.6%, and 16.6% versus 24.2%, respectively (p = 0.66). Multivariate analysis revealed that the presence of liver cirrhosis and vascular invasion were independently significant factors of poor overall survival.

CONCLUSIONS

Selected elderly patients with HCC benefited from resection as much as young patients, and age by itself may not be a contraindication to surgery. Postresection longterm prognosis in the elderly was determined by the presence of liver cirrhosis and vascular invasion.

Palliative gastrectomy for advanced gastric cancer

BACKGROUND/AIMS

Although palliative gastrectomy for advanced gastric cancer may be favorable in selected patients presenting with bleeding and obstruction, little has been reported about the clinical significance of palliative gastrectomy, including prognosis.

METHODOLOGY

A retrospective comparison between 84 patients with palliative gastrectomy (PG group) and 100 patients with unresectable operation (UO group) for advanced gastric cancer was carried out.

RESULTS

The incidence of serosal invasion, peritoneal dissemination, hepatic and lymph node metastases, and undifferentiated tissue type in the UO group were significantly higher than in the PG group. Median survival after operation in the PG group (20.6 months) was significantly longer than in the UO group (5.7 months). Also, in stage IVb patients, median survival time in the PG group (10.2 months) was significantly longer than in the UO group (5.0 months). However, median survival in the patients with synchronous liver metastasis between PG (8.4 months) and UO (4.6 months) groups was not significantly different. Survival rates after operation of 6 months, 1 year and 2 years in all patients between the palliative gastrectomy group versus UO group were 83.6% versus 38.3% (P < 0.01), 63.0% versus 9.3% (P < 0.01) and 35.2% versus 0% (P < 0.01), respectively.

CONCLUSIONS

Palliative gastrectomy compared to unresectable operation may be effective for improvement of prognosis even if stage IVb patients with peritoneal dissemination and/or distant lymph node metastasis. However, it may be unfavorable on survival of patients with synchronous liver metastasis.

Cytokine response to human liver ischemia-reperfusion injury during hepatectomy: marker of injury or surgical stress?

BACKGROUND/AIMS

The aim of this study was to evaluate the inflammatory or antiinflammatory cytokine response to ischemia-reperfusion during hepatectomy and to find a useful marker of injury or surgical stress during hepatic ischemia-reperfusion.

METHODOLOGY

In 9 patients with liver disease who underwent hepatectomy using the Pringle maneuver, serum cytokines, including alanine transaminase, aspartate transaminase, and hyaluronic acid, were measured just prior to vascular occlusion; 5, 10 and 15 min after initial clamping; and 3 min after initial declamping.

RESULTS

The mean concentrations of aspartate transaminase and alanine transaminase did not significantly differ before and after ischemia-reperfusion during hepatectomy. However, mean concentrations of hyaluronic acid after ischemia-reperfusion were significantly (P < 0.03) higher than before clamping. Although there were no significant differences in the mean concentrations of IL-1 beta, IL-6, IL-8, IL-10 and TNF-alpha among, before and after ischemia-reperfusion, the mean concentrations of granulocyte colony-stimulating factor after ischemia-reperfusion and macrophage colony-stimulating factor after reperfusion were significantly (P < 0.05) higher than before clamping.

CONCLUSIONS

Although hepatic parenchymal cell function was maintained after ischemia-reperfusion during hepatectomy, sinusoidal endothelial cell dysfunction was found. Release of granulocyte colony-stimulating factor and macrophage colony-stimulating factor after ischemia-reperfusion were also found. These cytokines and hyaluronic acid may be useful indicators in the early phase of human ischemia-reperfusion injury during hepatectomy.

Postoperative chemotherapy in elderly patients with advanced gastric cancer

BACKGROUND/AIMS

The definitive efficacy of postoperative chemotherapy in elderly patients with advanced gastric cancer has not been established. The aim of this study is to evaluate prognosis in elderly patients with advanced gastric cancer and the effect of postoperative chemotherapy on prognosis.

METHODOLOGY

Fifty-three patients, 75 years of age or older who underwent curative surgery for advanced gastric cancer were divided into 14 patients with postoperative chemotherapy (chemotherapy group) and 39 patients without postoperative chemotherapy (control group). Chemotherapy regimens were as follows: oral 5-FU alone (n = 11), intravenous mitomycin plus 5-FU: MF (n = 2), and MF plus oral 5-FU (n = 1). No prior chemotherapy or radiation was given.

RESULTS

There were no significant differences of clinical and pathological backgrounds between the two groups. The rate of death due to recurrent carcinoma was 50.0% in the chemotherapy group and 43.6% in the control group, the difference being insignificant. Although the median survival time of the chemotherapy group (40.4 months) was longer than in the control group (31.7 months), a significant difference did not exist between the groups. The 1-, 3-, and 5-year survival rates did not significantly differ between the chemotherapy group versus the control group, 85.7% versus 82.1%, 42.9% versus 51.3%, and 35.7% versus 46.2%, respectively.

CONCLUSIONS

Postoperative chemotherapy did not contribute to prolong survival in elderly patients with advanced gastric cancer mainly because the incidence of recurrent carcinoma was not reduced.

Hepatectomy of cavernous hemangioma with constitutional indocyanine green excretory defect

The constitutional ICG excretory defect with marked ICG retention in spite of other normal hepatic functions has not been so rare in Japan. However, there is no previous report of hepatectomy in a patient with this disease. We describe a successful case of hepatectomy for cavernous hemangioma with this disease and use of technetium-99m diethylenetriaminepentaacetic acidgalactosyl-human serum albumin (99mTC-GSA) liver scintigraphy as the preoperative assessment of the liver functional reserve. In our case, ICGR15 was more than 55%, however, a modified receptor index obtained from 99mTC-GSA liver scintigraphy was normal. Left lateral segmentectomy of the liver was performed without any perioperative complications. Hepatectomy of patients with the constitutional ICG excretory defect is possible if modified receptor index value obtained from 99mTC-GSA scintigraphy is within the normal range.

Survival and recurrence after hepatic resection of 386 consecutive patients with hepatocellular carcinoma

BACKGROUND

Although hepatic resection is one of the most effective treatments for hepatocellular carcinoma (HCC), the longterm results of hepatic resection of this malignancy are far from satisfactory. The potential benefits of hepatectomy for patients with HCC have not been fully delineated. This study aimed to identify surgical outcomes of 386 consecutive patients with HCC undergoing hepatic resection.

STUDY DESIGN

The retrospective study looked at records of 293 men and 93 women. The mean age was 63.2 years. Preoperative transarterial chemoembolizaton and portal vein embolization were performed in 138 patients (35.8%) and 8 patients (2.1%), respectively. Sixty-two patients (16.1 %) had major hepatectomy and the other 324 (83.9%) had minor hepatectomy. Thirty-seven of 386 patients (9.6%) had a noncurative operation.

RESULTS

The 30-day (operative) mortality rate was 4.1%, and there were 11 additional late deaths (2.9%). Two hundred fourteen of 327 patients (65.4%) had recurrence after curative resection. Unfavorable factors for survival and recurrence were resection between 1983 and 1990, Child class B or C, cirrhosis, a high value of indocyanine green retention-15, a large amount of intraoperative blood loss, stage IV disease, positive surgical margin, vascular invasion, and postoperative complications. Preoperative transarterial chemoembolization increased the recurrence rate and showed no contribution to prognosis. Currently, 106 patients (27.5%) are alive: 7 (1.8%) after more than 10 years and 43 (11.1%) after more than 5 years. Mean and median overall survivals after operation were 38 months and 29 months, respectively. The 5-year and 10-year overall or disease-free survival rates after hepatic resection were 34.4% and 10.5% or 23.3% and 7.8%, respectively.

CONCLUSIONS

The longterm survival rate after operation remains unsatisfactory mainly because of the high recurrence rate. Preoperative transarterial chemoembolization should be avoided because of a high risk of postoperative recurrence. Treatment strategies for recurrent HCC may play an important role in achieving better prognosis after operation, especially in patients with more than Child class B, cirrhosis, high values of indocyanine green retention-15, massive intraoperative blood loss, stage IV disease, positive surgical margin, vascular invasion, and postoperative complications.

Histochemical study of angiogenesis in basaloid squamous carcinoma of the esophagus

Angiogenesis of esophageal basaloid squamous carcinoma (BSC) was studied immunohistochemically and compared with that of squamous cell carcinoma (SCC). In tissues taken from six patients with esophageal BSC and 35 with esophageal SCC, angiogenesis was evaluated by measuring microvessel density (MVD), defined as the microvessel count determined using factor VIII-related antigen immunostaining, and by measuring immunoreactivity of vascular endothelial growth factor (VEGF) and thymidine phosphorylase (dThdPase). Three of the six patients with BSC had distant metastases. There was no difference of MVD between BSC and SCC (22.0 +/- 4.6 vs. 27.6 +/- 9.4). VEGF expression tended to be more frequently observed in BSC than in SCC (100% vs. 60.0%; p = 0.066). Strong expression of VEGF was detected in three BSC with distant metastases; however, there was no difference in the rate of strong VEGF expression between BSC and SCC. The MVD in the cases of BSC with strong VEGF expression, i.e. in the cases with distant metastases, was higher than that in the cases of BSC with weak VEGF expression (p=0.049). There was no difference in dThdPase expression of the cancer cells between BSC and SCC (50.0% vs. 54.3%), whereas the infiltrating stromal cells of all the BSC expressed dThdPase. Strong dThdPase expression in the cancer cells or in the infiltrating stromal cells was observed in two and three BSC, respectively. However, there were no differences in the rate of cancer cells or stromal cells with strong dThdPase expression between BSC and SCC. In one BSC with high MVD and distant metastases, VEGF and dThdPase were both strongly expressed. The vascularity of esophageal BSC was not different from that of SCC. VEGF may participate in angiogenesis of esophageal BSC and may influence the rate of metastasis in esophageal BSC patients. dThdPase may play a partial rule in angiogenesis and metastasis in some cases of BSC.

Prostaglandin E1 reduces thromboxane A2 in hepatic ischemia-reperfusion

BACKGROUND/AIMS

Prostaglandin E1 is well documented to exert cytoprotective effects in ischemia-reperfusion injury in the liver. This study was designed to evaluate the changes in prostanoid concentrations and to delineate the mechanism of the cytoprotective effect of prostaglandin E1 in hepatic ischemia-reperfusion injury.

METHODOLOGY

Mongrel dogs were divided into 3 groups: a control group, an ischemia-reperfusion group (I-R group), and a group that received prostaglandin E1 and was then subjected to ischemia-reperfusion. Liver ischemia was produced for 60 min using the Pringle maneuver. The concentrations of aspartate aminotransferase, alanine aminotransferase, prostaglandin I2, thromboxane A2, and lipid peroxides in hepatic venous blood were examined before and after the Pringle maneuver in the latter 2 groups, and at the corresponding points in the control group.

RESULTS

In the I-R group, aspartate aminotransferase and alanine aminotransferase after ischemia-reperfusion were significantly higher than those in the control group, and these values also rose significantly after ischemia-reperfusion in the prostaglandin E1-treated group. However, prostaglandin E1 administration suppressed significantly the increase compared with the I-R group. In the I-R group, prostaglandin I2, thromboxane A2, and lipid peroxide production in the liver increased 5 min after unclamping. The increases in thromboxane A2 and lipid peroxide production before and after ischemia-reperfusion were decreased, and prostaglandin I2 production was increased before ischemia-reperfusion in the group that was pretreated with prostaglandin E1.

CONCLUSIONS

Prostaglandin E1 is involved protecting against warm ischemic liver damage by not only suppressing the increased thromboxane A2 production, but also by increasing prostaglandin I2 production.

Changes in cardiopulmonary parameters during upper gastrointestinal endoscopy in patients with heart disease: towards safer endoscopy

BACKGROUND AND STUDY AIMS

Gastrointestinal endoscopy is an invasive examination. The aims of this study were to elucidate the effects and risks of upper gastrointestinal endoscopy with regard to cardiopulmonary functions in patients with heart disease, and to establish safety guidelines for use during endoscopy in this particular group of patients.

PATIENTS AND METHODS

The patients involved were 53 inpatients in whom upper gastrointestinal endoscopy was carried out before cardiac surgery. Their cardiac functions had been evaluated previously. Electrocardiography with two leads (II, V5) was used, and blood pressure and peripheral oxygen saturation (SpO2) were monitored throughout the procedure. The relationship between the changes in cardiopulmonary parameters during endoscopy and the cardiac functions was analyzed.

RESULTS

Heart rate increased immediately after insertion of the endoscope (P < 0.01). There was a significantly higher incidence of ventricular and supraventricular extrasystoles during observation of the second portion of the duodenum (P < 0.05). A lower cardiac index (P < 0.05) and a higher New York Heart Association (NYHA) functional classification (P < 0.05) were found in patients with oxygen desaturation than in patients without it. Two patients with severe coronary artery lesions showed marked ST-T depression, and these ischemic changes were thought to be due to increase in cardiac work during endoscopy.

CONCLUSIONS

Upper gastrointestinal endoscopy has many adverse effects on cardiopulmonary functions in patients with heart disease. In our study, the clinical value of very close monitoring and administration of oxygen for patients with heart disease was confirmed by objective data.

Four resections for hepatic metastasis from gastric cancer: histochemical analysis of cell proliferation, apoptosis, and angiogenesis

In a patient with gastric cancer (GC) associated with one synchronous and three metachronous hepatic metastases (HM), who underwent four hepatectomies, we carried out histochemical investigations regarding cell proliferation, apoptosis, and angiogenesis in the GC and HM. Tissue samples were taken from the primary GC and four HM. Ki-67 immunostaining was performed to evaluate cell proliferation and determine the labeling index (Ki-67 LI; ie, the percentage of cancer cells with nuclei stained for Ki-67). Terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate-biotin nick end labeling (TUNEL) was performed to evaluate apoptosis and determine the apoptotic index (ie, the percentage of TUNEL-positive cells), and immunostaining for factor VIII-related antigen was performed to evaluate angiogenesis and measure microvessel density (MVD). The Ki-67 LI was 43.2% in the primary GC and 39.9% in the synchronous HM, and the LI increased with the number of resections of metachronous HM. The apoptotic index was 3.36% in the primary GC, and 5.30% in the synchronous HM, and the index decreased after further resections of the metachronous HM. The MVD was 35 in the primary GC, and 22 in the synchronous HM, and it increased with the number of resections of metachronous HM. The primary GC in this patient may have strongly influenced the growth of HM through effects on cell proliferation, apoptosis, and angiogenesis.

Giant cavernous hemangioma of the liver: is tumor size a risk factor for hepatectomy?

The aim of this study was to evaluate whether hepatic giant cavernous hemangioma (GCH) tumor size is a risk factor for hepatectomy. Twenty patients with GCH of the liver were treated by hepatic resection. Eleven patients with maximum resected specimen tumor size of >10 cm (mean tumor size, 18.5 cm; group 1) were compared with the 9 patients with tumor size. <10 cm (mean tumor size, 8.6 cm; group 2). The incidence of major hepatectomy in group 1 was significantly higher than that in group 2 (P = 0.0241). Although there were no significant differences in preoperative liver function, or in fibrinogen or platelet counts between the two groups, the level of preoperative fibrin degradation product (FDP) in group 1 was significantly higher than that in group 2 (P = 0.0116). Mean intraoperative hemorrhage volume, blood transfusion volume, and operation time in group 1 vs group 2 were 7003 ml vs 1092 ml (P = 0. 0251), 2927 ml vs 556 ml (P = 0.0169), and 431 min vs 216 min (P < 0. 0001), respectively. The incidence of postoperative complications in group 1 (45.5%) was higher than that in group 2 (22.2%), although not significantly so. There was no operative mortality in either group. Tumor size significantly correlated with intraoperative blood loss, operation time, weight of resected liver, intraoperative blood transfusion volume, and preoperative FDP levels. GCH tumor size is a significant risk factor for hepatectomy mainly because of the massive intraoperative blood loss and blood transfusion associated with major hepatic resection. More careful preoperative management to decrease tumor size may increase the safety of surgery for GCH of the liver.

Complete disappearance of recurrent hepatocellular carcinoma with peritoneal dissemination and splenic metastasis: a unique clinical course after surgery

Spontaneous regression of hepatocellular carcinoma (HCC) is a rare phenomenon. We report a case of complete disappearance of intrahepatic, peritoneal and splenic metastases in HCC after hepatectomy using treatment with tegafur and uracil (UFT). The effect of UFT alone was not likely to have caused the disappearance of this tumour because HCC recurrence advance markedly within 5 months of surgery despite oral administration of UFT. This case demonstrates a unique postoperative clinical course that suggests spontaneous regression of HCC. This is the first case of complete disappearance of unresectable HCC with peritoneal seeding and splenic metastasis.

Effects of prostaglandin E1 administration during hepatectomy for cirrhotic hepatocellular carcinoma

BACKGROUND/AIMS

Prostaglandin E1 has been used in hepatectomy based on a few limited clinical studies suggesting that PGE1 improves liver function. The aim of this study was to evaluate the effects of PGE1 administration during hepatectomy for cirrhotic hepatocellular carcinoma.

METHODOLOGY

Forty-three patients undergoing hepatectomy for cirrhotic hepatocellular carcinoma were divided into 2 groups: hepatectomy with Prostaglandin E1 treatment (PG group; n = 19) and without Prostaglandin E1 treatment (control group; n = 24). Prostaglandin E1 (0.02-0.07 microgram/kg/min) was administered intravenously from beginning to end of surgery in the PG group.

RESULTS

There were no significant differences between groups with respect to age, gender, preoperative liver and renal function, or intraoperative variables such as blood loss, weight of resected liver and total clamping time by the Pringle maneuver. No patient had severe postoperative complications. Initial postoperative maximum concentrations of serum total bilirubin, creatinine, and blood urea nitrogen in the PG group were significantly lower than those in the control group.

CONCLUSIONS

Prostaglandin E1 administration during hepatectomy for cirrhotic heptocellular carcinoma resulted in improved renal and hepatic function.

Surgical outcome in cirrhotic patients with hepatitis C-related hepatocellular carcinoma

BACKGROUND/AIMS

The aim of this study was to clarify the surgical outcome in cirrhotic patients with hepatitis C-related hepatocellular carcinoma (HCC).

METHODOLOGY

The surgical outcome of 26 HCVAb-positive cirrhotic patients with hepatitis C antibody (the C-related HCC group) and 18 HCVAb-negative cirrhotic patients with (the non-C-related HCC group) undergoing hepatectomy for HCC were compared. The C-related HCC group was HCVAb[+], HBsAg[-] for hepatitis B surface antigen in 25 patients and HCVAb[+], HBsAg[+] in 1, and the non C-related HCC group was HCVAb[-], HBsAg[+] in 15 and HCVAb[-], HBsAg[-] in 3.

RESULTS

Preoperative aspartate and alanine aminotransferase in the C-related HCC group were significantly (P < 0.01) higher than in the non-C-related HCC group. There were no significant differences in the operative method, intraoperative blood loss and weight of resected liver or pathological data between the 2 groups. In the recurrence pattern, the incidence of multicentric occurrence in the C-related HCC group (53.3%) was significantly (P < 0.05) higher than in the non-C-related HCC group (7.7%). The mortality rate in both groups was 0% and no operative death was encountered. The crude survival and disease-free survival rates at 3 years were similar: 80.8% and 57.7% in the C-related HCC group and 77.8% and 55.6% in the non-C-related HCC group, respectively.

CONCLUSIONS

Although surgically treated cirrhotic patients with C-related HCC showed worse preoperative hepatitis status and a higher incidence of recurrence due to multicentricity compared with non-C-related HCC, the mortality and prognosis of patients with C-related HCC did not differ from that of non-C-related HCC. The indication of hepatic resection and consideration for the high incidence of postoperative multicentric occurrence in the patients with C-related HCC should therefore be more careful than in patients with non-C-related HCC.

Reresection for local recurrence of rectal cancer

Local recurrence is one of the major reasons that rectal cancer surgery is unsuccessful. The aim of this study was to investigate the surgical characteristics of patients undergoing reresection for local recurrence of rectal cancer. A total of nine patients were enrolled in this study, six of whom underwent total pelvic exenteration, one, posterior exenteration, one, abdominoperineal resection with sacral resection, and one, lymph node dissection alone. The mean operative time was 8 h 15 min, and the mean operative blood loss was 2 325 ml. Although major postoperative complications occurred in four patients (44%), there were no postoperative or hospital deaths. Lateral lymph node metastasis was detected in all four patients whose lateral lymph nodes were dissected or extirpated at the reresection. Two patients survived for more than 5 years without rerecurrence, and the cumulative 5-year survival rate was 26%. The para-aortic lymph nodes were the most common site of first rerecurrence. The results of this study indicate that patients who undergo reresection for local recurrence of rectal cancer are at high risk of devel-oping lateral or para-aortic nodal metastasis. Nevertheless, reresection may be a therapeutic option for the local recurrence of rectal cancer.

Hepatic function immediately after hepatectomy as a significant risk factor for early recurrence in hepatocellular carcinoma

BACKGROUND/AIMS

The aim of this study was to clarify the significant risk factors as they relate to early recurrence after hepatectomy in cirrhotic patients with hepatocellular carcinoma (HCC).

METHODOLOGY

We retrospectively investigated 42 cirrhotic patients undergoing hepatectomy for a single HCC. We compared the clinicopathologic features of 14 patients with early intrahepatic recurrence (recurrence was detected within 1 year after hepatic resection; Group 1) with 28 patients without recurrence or with late intrahepatic recurrence (recurrence was confirmed more than 1 year after hepatic resection; Group 2).

RESULTS

There were no significant differences in the pre-operative and intra-operative clinical background data or pathological data between the 2 groups. Regarding recurrence pattern, although not significant, the incidence of intrahepatic metastasis in Group 1 (85.7%) was higher than in Group 2 (50.0%). Maximum values of total bilirubin and albumin within 7 days after hepatectomy for patients in Group 2 were significantly better than those in Group 1. Aspatate aminotransferase (AST) and alanine aminotransferase (ALT) immediately after hepatectomy in Group 1 were also higher than in Group 2, although statistically insignificant. The overall 1-year and 3-year survival rates between Group 1 versus Group 2 were 85.7% versus 100% (p < 0.01) and 57.2% versus 90.0% (p < 0.01), respectively.

CONCLUSIONS

Hepatic functional damage immediately after hepatectomy is as significant risk factor for early intrahepatic recurrence in cirrhotic HCC. Careful perioperative management of hepatic function may therefore be important in preventing early recurrence and prolonging survival.

Hepatic resection of giant cavernous hemangioma of the liver

Surgical treatment of giant hemangioma of the liver is still controversial. The aim of this study is to examine the efficacy of hepatic resection for giant hemangioma of the liver. Twenty patients with giant cavernous hemangioma of the liver were treated by hepatic resection. The mean diameter of the hemangiomas was 13.9 cm (range, 6.5-30 cm). The surgical outcome was reviewed retrospectively. Major hepatectomy was performed in 14 patients and minor hepatectomy in 6 patients. Complications occurred in 7 of the 20 patients treated by hepatic resection. At a mean follow-up of 79 months (range, 12-173 months), 18 patients were symptom free whereas 2 patients had died--one died of pneumonia at 2 years and the other died of gastric cancer 6 years after surgery. Mean intraoperative hemorrhage and blood transfusion in all patients was 4,343 mL (range, 270-24,000 mL) and 1,860 mL (range, 0-8,800 mL) respectively. In the seven patients with preoperative high levels of fibrin degradation products (FDP), mean intraoperative hemorrhage and blood transfusion were markedly higher (9,371 mL and 3,714 mL respectively) than in the 13 patients without abnormal FDP (1,603 mL and 900 mL respectively). Preoperative hematologic status returned to normal after operation in all patients. Hepatic resection is a useful treatment for giant cavernous hemangioma of the liver. More careful management to reduce intraoperative hemorrhage is recommended to increase the safety of surgery, particularly in patients with preoperative abnormal FDP.

Synchronous gastric cancer associated with hepatocellular carcinoma: a study of 10 patients

BACKGROUND/AIMS

Little information regarding synchronous gastric cancer (GC) associated with hepatocellular carcinoma (HCC) is available. The aim of this study was to clarify the clinicopathologic features of synchronous GC associated with HCC, and we also discuss the diagnostic and therapeutic issues regarding them.

METHODOLOGY

In a series of 396 patients with GC and 340 patients with HCC, we investigated the clinicopathologic features of the patients with synchronous GC associated with HCC (HCC group; n=10). They were compared to the patients with resected GC without HCC (non-HCC group) which was divided into 2 groups: with chronic hepatic disease (CHD: CHD group; n=15) and without CHD (Control group; n=345).

RESULTS

The HCC group consisted of 10 of the 396 patients with GC (2.6%), and of 340 with HCC (2.9%). Eight node-negative early GC and 2 advanced GC cases were observed in the HCC group. Nine of these GC (90%) were well-differentiated adenocarcinoma. The tumor sizes of the HCC group were significantly smaller than those of the control group (p<0.05). The incidences of intestinal type and early GC in the HCC group were significantly higher than those in the control group, (p<0.05). However, there were no significant differences in any parameters between the HCC group and CHD group. With regard to early GC, there were no significant differences in any parameters, excluding the site of GC in the CHD group, between the HCC group and non-HCC group. Eight in the HCC group were surgically resected, and the post-operative period of these patients was uneventful. Although there were no significant differences in survival after surgery among the 3 groups, the survival of the patients with early GC in the HCC group was significantly worse than that in the control group (p<0.01).

CONCLUSIONS

The clinicopathologic features of synchronous GC associated with HCC are not very aggressive in most patients probably because of the early detection, and those of early GC with HCC appeared to resemble that of GC with CHD. Since early GC may not influence the clinical outcome of HCC patients, limited gastric resection can be recommended even when curative surgery for HCC is performed. By contrast, when advanced GC is present, curative gastrectomy with lymphadenectomy would be advisable to improve the long-term survival.

Efficacy of extended lymphadenectomy in the noncurative gastrectomy for advanced gastric cancer

BACKGROUND/AIMS

We retrospectively analyzed clinicopathologic data on 83 patients with advanced gastric cancer who underwent noncurative gastrectomy, with respect to the relation between the extent of lymphadenectomy and survival benefit.

METHODOLOGY

These 83 patients were divided into 44 patients with limited or simple lymph node dissection (D0 in 14 and D1 in 30: Group A) and 39 patients with extended lymph node dissection (D2: Group B).

RESULTS

The 1-year survival rate in Group B (82.1%) was significantly higher than in Group A (49.0%). However, the 3-year and 5-year survival rates did not significantly differ between Group A versus Group B, 39.7% versus 25.7% and 39.7% versus 20.5%, respectively. Median survival time after surgery with and without distant metastasis in Group B (21.5 months) was longer than in Group A (16.4 months), although not significant.

CONCLUSIONS

While gastrectomy with extended lymphadenectomy did not contribute to improve long-term survival in patients with noncurable advanced gastric cancer, the utility of extended lymph node dissections may be relevant to improved locoregional control, at least in the prognosis within 1 year after surgery. Not only extended lymphadenectomy but also aggressive chemotherapy may be needed to improve the long-term survival for such patients.

Snowboarding injuries of the chest: comparison with skiing injuries

BACKGROUND

Snowboarding injuries have become more common with the remarkable increase in the sport's popularity. However, although there are many reports of orthopedic injuries caused by snowboarding, there are few reports on injuries to the chest. In this study, we attempted to identify the characteristics of snowboarding injuries of the chest in comparison with alpine skiing injuries.

METHODS

Between December of 1988 and April of 1997, 1,579 and 9,108 patients were treated for snowboarding and skiing injuries, respectively. All patients were initially examined by emergency physicians who used chest x-ray film. Patients with known or suspected chest injuries were further examined by using chest computed tomography and ultrasonography by thoracic and general surgeons. A total of 96 snowboarding patients and 247 skiing patients had chest injuries.

RESULTS

The chest injuries among snowboarders accounted for 6.1% of all injuries compared with only 2.7% amongst skiers. Snowboarders with chest injuries were younger, more often beginners, and more frequently occurred during the afternoon than skiers. Several distinct patterns of injury were noted among these two groups. As the cause of injury, a riding mistake during jumping was significantly higher for snowboarders (50.0%) than for skiers (0%). The incidence of rib fracture during snowboarding (55.2%) was significantly higher than during skiing (41.3%). There were no mortalities in either group.

CONCLUSION

A riding mistake during improper jumping may be the primary cause of chest snowboarding injuries. Furthermore, snowboarders are much more likely to injure the chest, particularly by rib fractures, than skiers.

Idiopathic saccular aneurysm of the azygos vein

Idiopathic saccular aneurysm of the azygos vein is a rare condition. We report the case of a 52-year-old man with saccular aneurysm of the azygos vein who underwent surgical resection. Preoperative dynamic computed tomography revealed strong and rapid enhancement of the chest mass. Magnetic resonance imaging showed a thoracic tumor with low signal intensity on the T1-weighted image and coexistence of low and high signal intensity on the T2-weighted image. Intraoperative findings showed cystic dilatation of the azygos vein. Although an accurate preoperative diagnosis of saccular azygos vein aneurysm is difficult, especially differential diagnosis between this anomaly and mediastinal tumors, a markedly enhanced mass shown by dynamic computed tomography was useful for the preoperative diagnosis of this anomaly.