Oncological Impact of the Level of Inferior Mesenteric Artery Ligation in Low Rectal Cancer Surgery

BACKGROUND/AIM

This study aimed to evaluate the clinical impact of the level of inferior mesenteric artery (IMA) ligation in patients with advanced low rectal cancer.

PATIENTS AND METHODS

All enrolled patients (n=350) underwent curative resection of rectal cancer with D3 lymph node dissection, with either IMA (high-tie) or superior rectal artery (SRA) (low-tie) ligation.

RESULTS

There were 27 and 65 patients in the high-tie and low-tie groups, respectively. There was no significant difference in the postoperative complication rate. Postoperative anastomotic leakage developed in five patients in the low-tie group and none in the high-tie group. The overall recurrence rates were 37.0% (n=10) and 40.0% (n=26) in the high-tie and low-tie groups, respectively, with no significant difference between the two groups (p=0.748). Local recurrences and lymph node metastases developed in five and no patients in the high-tie group and in 13 and one patient in the low-tie group, respectively. In the multivariate analysis, pathological T4 and pathological N2 and N3 were independent poor prognostic factors for overall survival (OS), whereas left colic artery (LCA) preservation was not significant.

CONCLUSION

No significant difference in oncological outcomes was observed in advanced low rectal cancer surgery with respect to the level of the IMA ligation. Thus, the less complicated high-tie procedure should be adopted as a standard procedure.

Surgical outcomes of totally extraperitoneal repair for inguinal hernia: A retrospective multicenter propensity score-matched study

BACKGROUND

Laparoscopic surgical approaches, including total extraperitoneal repair (TEP), have been widely accepted for inguinal hernia repair in Japan. However, there are limited data regarding recurrence after TEP in Japan, given the limited versatility of this procedure. This study retrospectively evaluated the rates of hernia recurrence after TEP and open mesh repair at multiple Japanese centers.

METHODS

This retrospective study evaluated 1917 patients who underwent inguinal hernia repair at 32 institutions in the Oita prefecture between January 2014 and December 2015. Eligible patients were grouped according to whether they underwent TEP (1011 patients) or open mesh repair (636 patients). Propensity score matching was performed 1:1 (total: 1076 patients, 538 patients from each group). The outcomes of interest were recurrence, morbidity, and postoperative recovery.

RESULTS

The TEP and open mesh repair groups had similar baseline characteristics. After propensity score matching, there was no significant difference between the two groups in terms of recurrence rate (TEP: 0.5% vs open mesh repair: 1.0%, P = .375). However, the TEP group had significantly longer operating times (median: 70.2 min vs 65.0 min, P < .001), significantly less blood loss (0-5.1 mL vs 0-20.4 mL, P < .001), and significantly shorter postoperative hospital stays (median: 5.0 days vs 6.4 days, P < .001). The overall incidences of morbidity were 6.2% in the TEP group and 7.2% in the open mesh repair group (P = .535).

CONCLUSION

This multicenter retrospective study with propensity score matching revealed that the recurrence rates were similarly low for TEP and open mesh repair of inguinal hernia. Thus, a well-trained surgical team could use TEP as a standard procedure.

Prognostic Nutritional Index Considering Resection Range Is Useful for Predicting Postoperative Morbidity of Hepatectomy

BACKGROUND

Poor preoperative nutritional and immunological status are major risk factors for postoperative complications in patients with various malignancies. Lower preoperative prognostic nutrition index (PNI) is associated with higher rates of postoperative complications and poorer prognosis in those patients. The aim of this study was to analyze the predictive value of the PNI for post-hepatectomy complications in patients with hepatocellular carcinoma (HCC), and evaluate its utility in the surgical procedure.

METHODS

This retrospective study included 510 patients who underwent open hepatectomies for HCC. The predictive value of the preoperative nutritional and immunological status for postoperative complications was assessed using the PNI. Postoperative complications were defined as grade II or higher per the Clavien-Dindo classification. Postoperative complication rates were compared according to surgical procedure (major hepatectomy vs minor hepatectomy).

RESULTS

Patients with postoperative complications had significantly lower PNIs than those without (43.1 ± 5.5 vs 47.0 ± 5.7, P < 0.001). In the multivariate analysis, low preoperative PNI (< 45) was an independent risk factor for postoperative complications after hepatectomy (hazard ratio, 3.85). When patients were classified per their PNI (high vs low) and extent of surgical procedures (major vs minor), there were more complications among patients with low PNI than those with high PNI, regardless of the extent of surgical procedures. Specifically, the group of patients with low PNI who underwent major hepatectomy had significantly higher rates of postoperative complications than the other groups.

CONCLUSIONS

Adding the resection range to the PNI is useful for predicting the postoperative morbidities of hepatectomy patients.

Successful Conversion Surgery Following Chylous Ascites After Nivolumab for Advanced Gastric Cancer

CASE REPORT

A 75-year-old man who underwent nivolumab as the third-line chemotherapy for advanced gastric cancer had chylous ascites (CA) after the primary tumor shrank remarkably. Total parenteral nutrition and subcutaneous octreotide were initiated, and CA disappeared. Nivolumab was continued for a total of 23 courses. Computed tomography showed lymph node swelling; however, staging laparoscopy showed that peritoneal metastasis had disappeared. Therefore, conversion surgery and distal gastrectomy with D1+ dissection were performed.

RESULTS

The pathological diagnosis was type IV, poorly differentiated adenocarcinoma (por2) with signet ring cells, ypT2 (muscularis propria), without lymphatic or venous invasion, and no involvement of the proximal and distal margins. After the operation, no recurrence was observed over 7 months with no adjuvant chemotherapy.

CONCLUSION

Nivolumab has the potential to lead to R0 resection for patients with peritoneal carcinomatosis gastric cancer. To our knowledge, this is the first report of successful conversion surgery after nivolumab-related chylous ascites.

Mesenteric venous thrombosis as a rare complication of decompression sickness

Background

Decompression sickness (DCS) induced by extravascular and intravascular gas bubbles during decompression can present with varying manifestations, such as joint pain, numbness, cutaneous symptoms, and cardiopulmonary dysfunction. However, mesenteric venous thrombosis (MVT) is a rare complication of DCS. To the best of our knowledge, only a few cases have been reported, and surgical cases of MVT secondary to DCS have not yet been reported.

Case presentation

A 59-year-old man who was a fisherman and recreational diver dived to a depth of 100 feet. After diving, he noted abdominal and postcervical pain and visited a community hospital. Computed tomography (CT) revealed a large amount of intravenous gas, so he was diagnosed with DCS. He was then transferred to a previous hospital, where hyperbaric oxygen therapy (HBOT) was performed. HBOT reduced the amount of venous gas, but his abdominal pain worsened, so he was transferred to our hospital. CT showed pneumatosis cystoides intestinalis. Because of the possibility of intestinal necrosis, a laparoscopic examination was performed, which revealed necrosis of the transverse colon. We therefore performed a transverse colon resection. He was discharged 36 days after the surgery and followed an uneventful postoperative course.

Conclusions

DCS is likely to cause MVT. If intestinal necrosis is suspected, a laparoscopic examination may be useful for determining the diagnosis and treatment. MVT should be included as a differential diagnosis of abdominal pain that persists after HBOT.

Laparoscopic versus open surgery for locally advanced rectal cancer following neoadjuvant chemoradiotherapy with S-1: Short- and long-term outcomes of multicenter prospective phase II trials

793

Background: We have reported the effectiveness of neoadjuvant radiotherapy (RT) combined with S-1 in terms of compliance and pathologic response for locally advanced rectal cancer. In the present study, we aimed to evaluate the safety and efficacy of laparoscopic surgery for locally advanced rectal cancer following neoadjuvant RT combined with S-1 in comparison with open surgery. Methods: Two multicenter prospective phase II trials were conducted (UMIN003396, UMIN003398). A total of 63 patients with locally advanced rectal cancer classified as T3-4, N0-3, and M0 were enrolled, and neoadjuvant RT combined with S-1 and total mesorectal excision with D3 lymphadenectomy was performed. Of these, 57 patients were analyzed and divided into a laparoscopic group (LAP, n = 43) and open group (OP, n = 14). We evaluated the short- and long-term outcomes of laparoscopic surgery compared with open surgery by univariate and multivariate analyses. Results: In the patient background, there were no significant differences between the two groups except that cases with T3 and N0 were significantly higher in the LAP compared with the OP. In the operative findings, operation time was longer (mean 447 min vs. 352 min, p = 0.007) and blood loss was lesser (median 220 ml vs. 485 ml, p = 0.033) in the LAP than those in the OP. Although there were no significant differences observed in the incidence of perioperative and late complications between the two groups, reoperation within 30 days was significantly less in the LAP compared with the OP (1 case vs. 5 cases, p = 0.0004). In the multivariate analysis, a distance of the tumor from anal verge within 3 cm was the independent risk factor for reoperation within 30 days. Furthermore, estimated 5-year disease-free survival (LAP 72 % vs. OP 73 %, p = 0.945) and 5-year overall survival (LAP 76 % vs. 75 %, p = 0.836) didn’t significantly differ between the two groups in the Kaplan–Meier curve. Conclusions: The findings of this study demonstrated that laparoscopic surgery for locally advanced rectal cancer following neoadjuvant RT combined with S-1 could be an optional procedure in terms of short- and long-term outcomes. Clinical trial information: UMIN000003396, UMIN000003398.

Abstract P6-05-18: A53, cell cycle phenotype and Cdc7 kinase: Identifying patients likely to benefit from targeted Cdc7 therapy

We previously reported multiparameter analysis of cell cycle regulatory proteins in breast cancer and identified three prognostic ‘cell cycle phenotypes’. Phenotype iii represents cells traversing through the mitotic cell division cycle and is associated with poor prognosis and high Cdc7 levels1. Cdc7 kinase initiates DNA synthesis at chromosomal replication origins and is rate-limiting for S phase entry. In cell-based studies we discovered a new, p53-dependent cell cycle checkpoint which reversible arrests normal cells in G1 phase if DNA replication initiation is perturbed. In cancer cells treated with Cdc7 inhibitors this checkpoint function is lost, resulting in aberrant S phase entry and subsequent apoptotic cell death2,3. Cdc7 kinase is therefore emerging as a novel therapeutic target in cancers bearing mutant p53.

In this study we investigated whether the inclusion of p53 mutation status adds further prognostic power to the cell cycle phenotype. We also questioned whether p53 mutant breast cancers express high Cdc7 levels and are thus more likely to be of cell cycle phenotype iii (susceptible to Cdc7-targeted therapy).

Our results show that Cdc7 levels are inversely correlated with p53 mutation status (n = 173) and are highest in cell cycle phenotype iii and harder to treat Her-2 and triple negative breast cancer subgroups. Cell cycle phenotype is the strongest predictor of early relapse compared to p53, Ki67 and Cdc7 on univariate analysis and remains so on multivariate analysis after adjusting for p53 status (HR = 3.80, p = 0.002).

These findings support the supposition that p53 negatively regulates Cdc7 expression. Combined testing for p53 status, cell cycle phenotype and Cdc7 expression identifies those patients with breast cancer most likely to benefit from targeted therapy with Cdc7 inhibitors.

1 Br J Cancer. 2009 Mar 24;100(6):959-70

2 EMBO J. 2010 Oct 6;29(19):3381-94

3 Am J Pathol. 2010 Oct;177(4):2034-45.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P6-05-18.

Initial Japanese experience with the LAP-BAND system

INTRODUCTION

Laparoscopic bariatric surgery has gradually spread in Japan since it was introduced in 2000. In 2005, we introduced laparoscopic adjustable gastric banding (LAGB) with the LAP-BAND system into Japan. Here, we evaluate our intermediate-term results with the LAP-BAND system.

METHODS

Between August 2005 and June 2010, 27 Japanese patients with morbid obesity (BMI ≥ 35 kg/m(2) ) underwent LAGB with the LAP-BAND system in our institution. Our patients' average weight was 111 kg and BMI was 41 kg/m(2) . All LAGB procedures were performed through the pars flaccida pathway with band fixation using gastric-to-gastric sutures. The average follow-up period was 48 months.

RESULTS

All procedures were completed laparoscopically. One early complication (sudden cardiac arrest due to postoperative bleeding) and three late complications (port trouble, megaesophagus, and band slippage) were experienced, and reoperations were performed in three of the patients. Weight loss and percentage of excess weight loss on average were 26 kg and 53% after 3 years and 22 kg and 53% after 6 years, respectively. In line with this good weight loss, comorbidities, especially those of type 2 diabetes and metabolic syndrome were frequently resolved or improved.

CONCLUSION

LAGB with the LAP-BAND system appears to be beneficial in obese Japanese patients.

Operative timing of laparoscopic cholecystectomy for acute cholecystitis in a Japanese institute

These authors suggest that the best timing of laparoscopic cholecystectomy for acute cholecystitis in Japan may be within 24 hours of the onset of the disease.

Background and Objectives:

In patients with acute cholecystitis who cannot undergo early laparoscopic cholecystectomy (within 72 hours), 6 weeks to 12 weeks after onset is widely considered the optimal timing for delayed laparoscopic cholecystectomy. However, there has been no clear consensus about it. We aimed to determine optimal timing for delayed laparoscopic cholecystectomy for acute cholecystitis.

Methods:

Medical records of 100 patients who underwent standard laparoscopic cholecystectomy were reviewed retrospectively. Patients were divided into group 1, patients undergoing laparoscopic cholecystectomy within 72 hours of onset; group 2, between 4 days to 14 days; group 3, between 3 weeks to 6 weeks; group 4, >6 weeks.

Results:

No significant differences existed between groups in conversion rate to open surgery, operation time, blood loss, or postoperative morbidity, and hospital stay. However, total hospital stay in groups 1 and 2 was significantly shorter than that in groups 3 and 4 (P<.01). In addition, the total hospital stay in group 3 was also significantly shorter than that in group 4 (P<.01).

Conclusions:

Best timing of laparoscopic cholecystectomy for acute cholecystitis may be within 72 hours, and the delayed timing of laparoscopic cholecystectomy in patients who cannot undergo early laparoscopic cholecystectomy is probably as soon as possible after they can tolerate laparoscopic cholecystectomy.

Implications of portal vein thrombosis after splenectomy for patients with idiopathic portal hypertension

PURPOSE

Idiopathic portal hypertension (IPH) is considered to be closely related to portal vein thrombosis (PVT). The aim of this study was to clarify the incidence, clinical characteristics, and outcomes of PVT in patients with IPH after splenectomy.

METHODS

We investigated the rates, clinical characteristics, and outcomes of PVT in 18 patients who underwent splenectomy for IPH, during a mean follow-up period of 152 ± 83 months.

RESULTS

Seven of the 18 patients (39%) experienced gastrointestinal bleeding, which was from the varices in 4. Eight patients (44%) had PVT, and the mean interval until its detection after splenectomy was 22 ± 41 months. The cumulative gastrointestinal bleeding rates 5, 10, and 15 years after surgery were 24%, 31%, and 41%, respectively. The cumulative survival rates 5, 10, and 15 years after surgery were 94%, 74%, and 65%, respectively. There were no significant differences in the cumulative gastrointestinal bleeding and survival rates between patients with and those without PVT.

CONCLUSION

Despite the high incidence of PVT in IPH patients postsplenectomy, it may not be related to their gastrointestinal bleeding or prognosis.

A comparative study of the long-term outcomes after laparoscopy-assisted and open left lateral hepatectomy for hepatocellular carcinoma

BACKGROUND

Laparoscopic hepatectomy was initially reported in 1992. However, the reported experiences are scarce, and this operation has not been a standard procedure until now. The aims of this study were to assess our results of laparoscopy-assisted left lateral hepatectomy for hepatocellular carcinoma (HCC) and to compare them with those of open conventional procedures.

METHODS

From 1984 to 2002, left lateral hepatectomy for HCC less than 5 cm in diameter was carried out in 21 patients. Ten patients received a laparoscopy-assisted procedure, and remaining 11 patients received an open procedure.

RESULTS

There were no significant differences in the operation time, blood loss, resected liver weight, and resection margin between the 2 groups. The total time that analgesics were given, body temperature on postoperative day 1, weight loss on postoperative day 7, and postoperative hospital stay in the laparoscopic group were significantly better than in the conventional group. With regard to the long-term prognosis, there were no differences in patient survival or disease-free survival rates between the 2 groups.

CONCLUSIONS

Laparoscopy-assisted left lateral hepatectomy for HCC is superior to the conventional open surgery in terms of its short-term results and does not cause the long-term survival to deteriorate. Therefore, laparoscopic hepatectomy may be an alternative choice for treatment of HCC.

Infectivity of HBV DNA positive donations identified in look-back studies in Hyogo-Prefecture, Japan

AIMS/OBJECTIVES

To clarify transfusion incidence of hepatitis B virus (HBV) infected blood negative for mini pool-nucleic acid amplification testing (MP-NAT).

BACKGROUND

Japanese Red Cross (JRC) blood centres screen donated blood to avoid contamination with HBV. However, a low copy number of HBV may be overlooked.

METHODS/MATERIALS

In Hyogo-Prefecture, JRC blood centres screened 787 695 donations for HBV from April 2005 to March 2009. Of these, 685 844 were donations from the repeat donors. To detect the donors with HBV, serological tests, MP-NAT and/or individual donation (ID)-NAT were performed. To detect the recipients with transfusion-transmitted HBV infection (TTHBI), serological analysis and/or ID-NAT were performed.

RESULTS

In this study, 265 of the 685 844 repeat donations were serologically and/or MP-NAT positive for HBV. Their repository samples from the previous donation were examined in a look-back study; 13 of the 265 repository samples proved ID-NAT positive. Twelve recipients were transfused with HBV-infected blood components derived from 10 of the 13 HBV-infected donors. Only 1 of the 12 recipients was identified as TTHBI case. Seven of the 12 recipients escaped from our follow-up study and 4 recipients were negative for HBV during the observation period.

CONCLUSION

On the basis of the look-back study among the repeat donors in Hyogo-Prefecture, Japan, donations with HBV-infected blood negative for MP-NAT occurred with a frequency of 13 in 685 844 donations (∼1/53 000 donations). However, more than half of the recipients transfused with HBV-infected blood negative for MP-NAT could not be followed up. It is necessary to establish a more cautious follow-up system.

[Current status of laparoscopic bariatric surgery]

During recent years, obesity has emerged as a major public health problem in the world. It is generally agreed that non-surgical therapies do not solve the problem of morbid obesity (BMI > or =35 kg/m). Therefore, bariatric surgery has been frequently performed for treatments of morbid obesity in American and European countries. In 2008, more than 340,000 bariatric surgical operations (> or =90% laparoscopically) were done, and the typical procedures were laparoscopic Roux-en-Y gastric bypass, adjustable gastric banding and sleeve gastrectomy. Bariatric surgery certainly reduces weight and improves comorbidities and survival in morbidly obese patients. Recently, several bariatric procedures have been also introduced into Japan, and their excellent results in Japanese patients have been already reported.

Increased levels of both carbohydrate antigen 19-9 and duke pancreatic monoclonal antigen type 2 reflect postoperative prognosis in patients with pancreatic carcinoma

OBJECTIVES

It is important to identify useful tumor markers for the prediction of postoperative outcomes in patients with pancreatic carcinoma (PC).

METHODS

A retrospective study was performed in 87 patients who underwent surgical resection for PC. Preoperative levels of tumor markers such as carbohydrate antigen 19-9 (CA19-9) and duke pancreatic monoclonal antigen type 2 (DUPAN-2) were estimated and analyzed in relation to disease-specific survival (DSS).

RESULTS

The CA19-9 level did not correlate with the DUPAN-2 level (R=-0.057). Prognosis correlated with CA19-9 levels, and patients with 185 U/mL or lower CA19-9 level showed significantly better DSS than patients with 186-U/mL or higher CA19-9 level (P=0.015). Patients with 151- to 800-U/mL DUPAN-2 level showed significantly worse DSS than patients with 801-U/mL or higher DUPAN-2 level (P=0.0023), so the prognosis was reversely related to the DUPAN-2 level. Patients with increased levels of both CA19-9 and DUPAN-2 showed significantly worse DSS than the patients without elevated levels (P<or=0.0023). The independent predictors of poor DSS (hazards ratio, 95% confidence interval) were the following: non-well-differentiated adenocarcinoma (2.35, 1.28-4.53), invasion of the portal vein (2.57, 1.47-4.47), and increased levels of both CA19-9 and DUPAN-2 (3.01, 1.72-5.32).

CONCLUSIONS

The increased levels of both CA19-9 and DUPAN-2 closely reflect prognosis in patients with PC.

Ampullary cancer and preoperative jaundice: possible indication of the minimal surgery

BACKGROUND/AIMS

Obstructive jaundice is common symptom of carcinoma of the ampulla of Vater. In the present study we evaluated association between preoperative jaundice and prognosis and possible indication of the minimal surgery.

METHODOLOGY

Clinicopathological features of 50 patients who underwent curative resection were examined retrospectively and statistically analyzed.

RESULTS

Thirty-two of the 50 patients (64%) had preoperative jaundice, and these patients had poorer survival compared with these without jaundice (5 year survival 57.2% vs. 100%, p < 0.01). Preoperative jaundice, serum carbohydrate antigen 19-9 level, pancreatic invasion, lymphatic invasion, venous invasion, perineural invasion, duodenal invasion, margin status, lymph node metastasis, and T stage were shown to be significant prognostic factors. In the 18 patients without preoperative jaundice, lymphatic invasion was significantly related to lymph node metastasis. In addition, 12 of the 14 patients without jaundice and lymphatic invasion were diagnosed as T1N0 (stage IA) disease, and all the tumors were papillary or well-differentiated adenocarcinoma.

CONCLUSIONS

Preoperative jaundice may reflect advanced-stage in case of ampullary cancer. Radical surgery may not be necessary in patients without preoperative jaundice if the tumor is diagnosed as a papillary or well-differentiated adenocarcinoma without lymphatic invasion.

Lymphatic invasion: an important prognostic factor for stages T1b-T3 gallbladder cancer and an indication for additional radical resection of incidental gallbladder cancer

BACKGROUND

Laparoscopic cholecystectomy is being performed with increasing frequency worldwide. This has led to more frequent discovery of incidental gallbladder cancer (IGBC) and in turn to the need for an independent prognostic factor for stages T1b-T3 gallbladder cancer so that is can be determined clinically which cases of IGBC are indicated for additional radical resection (ARR).

METHODS

A retrospective study was conducted that included 72 patients who underwent macroscopically curative surgical resection (R0, R1) at our center for stages T1b-T3 GBC. Survival analysis was performed, and the usefulness of ARR was analyzed in 15 patients with IGBC.

RESULTS

Univariate analysis of disease-specific survival showed stage T3, histologic grade II-IV, lymphatic invasion, vessel invasion, perineural invasion, lymph node metastasis, and a positive resection margin to be factors indicative of poor prognosis. Independent predictors of poor disease-specific survival were stage T3 (hazard ratio, 2.33 [95% CI, 1.10-4.95]), lymphatic invasion (5.97 [1.29-27.6]), and a positive resection margin (3.17 [1.51-6.63]). Among the 15 IGBC patients, 4 of 5 patients without lymphatic invasion were cured, 2 of whom underwent cholecystectomy alone; 4 of 10 patients with lymphatic invasion did not undergo ARR, and the cancer recurred in all 4 patients; the other 6 patients underwent ARR, and 4 of them were cured by reoperation.

CONCLUSIONS

Lymphatic invasion well reflects the malignant phenotype of stages T1b-T3 GBC. We advocate ARR for IGBC patients with lymphatic invasion.

Increased heat-shock protein 90 expression contributes to impaired adaptive cytoprotection in the gastric mucosa of portal hypertensive rats

BACKGROUND AND AIMS

Portal hypertensive (PHT) gastropathy results in an increased susceptibility to damage. Adaptive cytoprotection against ethanol-induced damage is impaired in the gastric mucosa of rats with portal hypertension. Excessive nitric oxide (NO) production occurs in portal hypertension and is mediated in part via heat-shock protein (Hsp)90 production. The aim of this study was to investigate the relation between adaptive cytoprotection after exposure to ethanol and gastric expression of Hsp90 in PHT rats.

METHODS

Portal hypertension was induced in rats by staged portal vein occlusion. Adaptive cytoprotection to 70% ethanol was evaluated by assessing the injury index of the gastric mucosa with or without pretreatment with 10% ethanol. Expression of Hsp90 mRNA was evaluated by real-time polymerase chain reaction, and expression of Hsp90 protein was evaluated by western blotting. The effect of Hsp90 inhibition in PHT rats was evaluated by administration of geldanamycin.

RESULTS

Gastric Hsp90 mRNA expression in PHT rats was significantly less than that in sham-operated (SO) controls. However, after 10% ethanol pretreatment, Hsp90 mRNA expression was significantly greater in PHT rats than in SO controls. In PHT rats, gastric Hsp90 protein expression after 10% ethanol pretreatment was significantly greater than that without the pretreatment. However, the pretreatment had no effect on the injury index compared to SO rats. Administration of geldanamycin prior to 10% ethanol pretreatment significantly decreased the injury index in response to 70% ethanol in the PHT rats.

CONCLUSIONS

These results show that 10% ethanol pretreatment markedly increases gastric Hsp90 expression in PHT rats. Excessive production of Hsp90 may contribute impaired adaptive cytoprotection.

[Endoscopic and laparoscopic treatments for morbid obesity--endoscopic intragastric balloon placement and laparoscopic adjustable gastric banding]

We have introduced intragastric balloon placement (IGB) and laparoscopic adjustable gastric banding (LAGB) into Japan since 2004. We performed IGB in 23 morbidly obese patients with 40 +/- 9 kg/m2 (BMI). When the balloon were removed after 5 months, the averaged weight loss and percent excess weight loss (%EWL) were 12 kg and 27%, respectively. Twenty-seven patients with 45 +/- 9 kg/m2 underwent LAGB in our institute, and after 12 and 24 months, the average weight loss were 25 kg and 35 kg, and %EWL were 40% and 54%. There was no serious complication after both the treatments. IGB and LAGB are safe and effective treatments for Japanease patients with morbid obesity.

Pylorus-preserving pancreaticoduodenectomy in patients undergoing chronic hemodialysis

This report describes three patients who underwent a pylorus-preserving pancreaticoduodenectomy (PpPD) and received maintenance hemodialysis due to chronic renal failure. The three cases were diagnosed to have bile duct cancer, intraductal papillary mucinous neoplasm, and carcinoma of the ampulla of Vater, respectively. They underwent chronic hemodialysis for 7.7 years. They all underwent a PpPD with lymph node dissection. The mean operation time was 373 min and mean blood loss was 647 ml. During the postoperative courses, hemodialysis was restarted on postoperative day 1 in all three cases. In the three patients, only minor complications were experienced and these were treated conservatively. The mean postoperative hospital stay was 48 days. Two patients are still alive 135 and 21 months after the operation, respectively, but the other patient died of another disease 21 months after the PpPD. A PpPD may therefore be safe and feasible even in patients receiving chronic hemodialysis.

Viscoexpression of large free floating Cysticercus cyst from the anterior chamber of the eye by double incision technique

We describe a case of 16-year-old girl who reported with diminution of vision in left eye for past seven months with appearance of white reflex. Slit lamp biomicroscopy revealed the presence of a live grayish white cyst in the anterior chamber. The ultrabiomicroscopic evaluation revealed a large live Cysticercus cellulosae cyst in anterior chamber. The CT-scan of the brain revealed multiple non-contrast enhanced lesions with calcification in brain parenchyma. The patient was started on oral prednisolone and oral albendazole. The cyst was removed in toto from the eye by double incision technique. The patient achieved visual acuity of 6/12 post-operatively.

Direct invasion to the colon by hepatocellular carcinoma: Report of two cases

Although hepatocellular carcinoma (HCC) is a common tumor, direct invasion of the gastrointestinal tract by HCC is uncommon. Recently, we encountered two cases of HCC with direct invasion to the colon. The first patient was a 79-year-old man who underwent transarterial chemo-embolization (TACE) for HCC 1.5 years prior to admission to our hospital. Computed tomography (CT) showed a 7.5-cm liver tumor directly invading the transverse colon. Partial resection of the liver and transverse colon was performed. The patient survived 6 mo after surgery, but died of recurrent HCC. The second patient was a 69-year-old man who underwent TACE and ablation for HCC 2 years and 7 months prior to being admitted to our hospital for melena and abdominal distension. CT revealed a 6-cm liver tumor with direct invasion to the colon. The patient underwent partial resection of the liver and right hemicolectomy. The patient recovered from the surgery. But, unfortunately, he died of liver failure due to liver cirrhosis one month later. Although the prognosis of HCC that has invaded the colon is generally poor due to the advanced stage of the disease, surgical resection may be a favorable treatment option in patients with a good general condition.

Initial Japanese experience with intragastric balloon placement

BACKGROUND

We introduced intragastric balloon placement in Japan and evaluated the initial data.

METHODS

Between December 2004 and March 2008, intragastric balloons [BioEnterics Intragastric Balloon (BIB) system] were placed in 21 Japanese patients with obesity [six women, 15 men; mean age 40+/-9 years; mean body mass index (BMI) 40+/-9 kg/m2]. The inclusion criteria were morbid obesity (BMI>or=35 kg/m2), the presence of obesity-related disorders, and failure with conventional treatments for at least 6 months. The balloon was routinely removed under endoscopy after 5 months.

RESULTS

No serious complications occurred, but in two of the 21 patients (9.5%), early removal (within 1 week) of the balloon was required due to continuous abdominal discomfort. Two other patients (9.5%) could not control their eating behavior and were considered unresponsive to the treatment, and their balloons were also removed before 5 months. Seventeen of the 21 patients (81%) finished the treatment, and the average weight loss and percent excess weight loss (%EWL) at the time the balloons were removed were 12+/-5 kg and 27+/-9%, respectively. Eight patients were followed for 1 year without intervention of consecutive bariatric surgery, and at that time, four of these patients had kept more than 20% of %EWL. The other patients regained their weight in the first year.

CONCLUSIONS

Intragastric balloon placement is a safe and effective procedure in obese Japanese patients, and about half of the patients will maintain their weight loss after the balloon is removed.

Additional effect of visceral fat resection in an obese rat model of gastric banding

BACKGROUND

There is accumulating agreement that bariatric surgery is currently the most efficacious and enduring treatment for clinically severe obesity, and as a result, the number of bariatric surgeries performed worldwide has increased in recent years. Although the function of visceral fat has gradually become clear, the effect of visceral fat resection is still unknown. The aim of this study was to clarify the additional effect of visceral fat resection in an obese rat model of gastric banding.

METHODS

Forty male Zucker fatty rats were divided into four groups: the control group, visceral fat resection group, gastric banding group, and gastric banding with visceral fat resection group. They were followed for 8 weeks after surgery, and their body weight change, cumulative food intake, metabolic parameters, and adipocytokines were measured.

RESULTS

The gastric banding rats either with or without visceral fat resection showed significant decreases in weight gain, cumulative food intake, and levels of metabolic parameters compared to the control rats. There were no significant differences in weight gain and cumulative food intake between gastric banding with and without visceral fat resection. However, gastric banding with visceral fat resection resulted in lower plasma levels of free fatty acid and TNF-alpha compared to gastric banding alone, and expression of adiponectin mRNA in the adipose tissue was significantly decreased with the addition of visceral fat resection compared with banding alone. There were no significant differences in any parameters between controls and rats receiving visceral fat resection alone.

CONCLUSION

Visceral fat resection may improve adipocytokines and free fatty acid in an obese rat model of gastric banding. However, further studies are necessary before the procedure can be considered an option on bariatric surgery.

Metastasis of hepatocellular carcinoma to spleen and small intestine

Metastasis of cancer to the spleen or small intestine is rare. We encountered a case of hepatocellular carcinoma (HCC) with splenic and jejunal metastases. A 60-year-old man was referred to us in February 2005 with a diagnosis of splenic tumor. Since 2001, he had been treated repeatedly for HCC with liver cirrhosis due to hepatitis C virus infection; partial liver resection, transcatheter arterial chemo-embolization, and radiofrequency ablation therapy had been performed. In October 2004, he had undergone partial pulmonary resection due to metastasis of HCC to the lung. The splenic tumor, which was detected by computed tomography, seemed to be a metastasis of HCC. Splenectomy was performed for the splenic tumor, and a jejunal tumor was discovered and also resected. Both the splenic and jejunal tumors were diagnosed pathologically as metastases from the HCC. After repeated treatment for HCC, metastases can appear in various organs; thus, careful observation is necessary during follow-up.

Short- and long-term outcomes after hepatic resection for hepatocellular carcinoma with concomitant esophageal varices in patients with cirrhosis

BACKGROUND

Hepatic resection for hepatocellular carcinoma (HCC) in cirrhotic patients with esophageal varices (EV) is often avoided because of poor liver function reserve. Outcomes of resection in such cases have not been fully investigated.

METHODS

We conducted a retrospective study of 134 cirrhotic patients (Child-Pugh class A or B) who underwent hepatic resection for HCC, comparing short- and long-term outcomes in patients with EV (n = 31) to those in patients without EV (n = 103).

RESULTS

Patients with EV had higher tumor differentiation, fewer instances of portal invasion, lower liver function reserve, and more limited resections than did patients without EV. Of 31 patients with EV, four died of postoperative complication, and nine of liver failure, seven of HCC, two of ruptured EV, and two of other causes. Median survival time for patients who died of liver failure was 59 months. Mortality and morbidity rates after hepatic resection did not differ between patients with and without EV. The 5-year overall survival rate was significantly higher in patients with EV (70.1%) than in those without EV (47.5%, P = 0.045) but did not differ between patients without portal invasion with and without EV (P = 0.55). Presence of EV was not an independent predictor for survival.

CONCLUSIONS

Short- and long-term outcomes of hepatic resection in HCC patients with and without EV are similar. Limited hepatic resection for early-stage tumor is an option for Child-Pugh class A or B patients with EV.

Short- and long-term outcomes after hepatic resection for hepatocellular carcinoma with concomitant esophageal varices in patients with cirrhosis

BACKGROUND

Hepatic resection for hepatocellular carcinoma (HCC) in cirrhotic patients with esophageal varices (EV) is often avoided because of poor liver function reserve. Outcomes of resection in such cases have not been fully investigated.

METHODS

We conducted a retrospective study of 134 cirrhotic patients (Child-Pugh class A or B) who underwent hepatic resection for HCC, comparing short- and long-term outcomes in patients with EV (n = 31) to those in patients without EV (n = 103).

RESULTS

Patients with EV had higher tumor differentiation, fewer instances of portal invasion, lower liver function reserve, and more limited resections than did patients without EV. Of 31 patients with EV, four died of postoperative complication, and nine of liver failure, seven of HCC, two of ruptured EV, and two of other causes. Median survival time for patients who died of liver failure was 59 months. Mortality and morbidity rates after hepatic resection did not differ between patients with and without EV. The 5-year overall survival rate was significantly higher in patients with EV (70.1%) than in those without EV (47.5%, P = 0.045) but did not differ between patients without portal invasion with and without EV (P = 0.55). Presence of EV was not an independent predictor for survival.

CONCLUSIONS

Short- and long-term outcomes of hepatic resection in HCC patients with and without EV are similar. Limited hepatic resection for early-stage tumor is an option for Child-Pugh class A or B patients with EV.

Reduction of ethanol-induced injury in portal hypertensive gastric mucosa of rats by induction of heat shock protein 72 by geranylgeranylacetone

Portal hypertensive (PHT) gastropathy has an increased susceptibility to damage due to noxious factors. Heat shock protein (HSP) 72 has a protective effect against gastric mucosal injury and geranylgeranylacetone (GGA) is an inducer of HSP 72. However, it remains unclear how HSP 72 influences the PHT gastric mucosa. The aim of the present study was to investigate HSP 72 induction by GGA and the protective effect to gastric mucosa in PHT rats. PHT rats were produced by staged portal vein occlusion, and GGA 200 mg/kg was orally administered. Expression of HSP 72 protein in the gastric mucosa was evaluated by enzyme-linked immunosorbent assay, and gastric mucosal damage against 70% ethanol (10 mL/kg) following GGA or vehicle treatment was also estimated. Expression of mucosal HSP 72 after vehicle administration was significantly higher in the PHT rats compared with the sham-operated rats. After GGA treatment, portal pressure did not change but HSP 72 was significantly increased in the gastric mucosa of both groups. Ethanol-induced gastric mucosal damage was significantly decreased due to GGA treatment in the PHT rats, but not in the sham-operated rats. These findings suggest that HSP 72 expression is enhanced in PHT gastric mucosa and plays an important role in gastric mucosal protection. The induction of HSP 72 by GGA may therefore effectively prevent mucosal injury in the PHT stomach.

Prognosis of patients with intrahepatic recurrence after hepatic resection for hepatocellular carcinoma: a retrospective study

AIMS

Hepatic resection is the most effective therapy for hepatocellular carcinoma (HCC); however, intrahepatic recurrence is common. Predictors of survival after intrahepatic recurrence have not been fully investigated. To clarify the prognosis and choice of treatment of intrahepatic recurrence after hepatic resection, we conducted a comparative retrospective analysis of 147 patients with HCC who underwent hepatic resection.

METHODS

We retrospectively examined the relations between clinicopathologic factors, including the number of recurrent intrahepatic tumors and long-term prognosis after recurrence in 147 HCC patients who underwent resection. We also examined long-term survival after recurrence based on treatment types and recurrence pattern.

RESULTS

Patients with multiple tumors (n=83) showed less tumor differentiation, more frequent portal invasion, a higher alpha-fetoprotein level, and larger tumors than did patients with solitary tumor (n=64). In the solitary tumor group, local ablation therapy and repeat hepatic resection were performed in 25 and 10, respectively. In the multiple tumor group, 59 were treated by transarterial chemoembolization. Multivariate analysis showed intraoperative blood transfusion and multiple tumors to be independent risk factors for poor cancer-related survival after recurrence. By subset analysis based on treatment types and recurrence pattern, survival after recurrence was significantly better in patients treated by local ablation therapy than those treated by other therapies in both solitary and multiple tumor groups.

CONCLUSIONS

For patients with solitary recurrence, a good prognosis is predicted. Local ablation therapy is a best candidate for treatment of solitary and multiple intrahepatic recurrences after hepatic resection.

A small interfering RNA targeting proteinase-activated receptor-2 is effective in suppression of tumor growth in a Panc1 xenograft model

Proteinase-activated receptor-2 (PAR-2), which is a G protein-coupled receptor, is activated in inflammatory processes and cell proliferation. We previously demonstrated that an anti-PAR-2 antibody suppresses proliferation of human pancreatic cells in vitro. However, there have been no studies of PAR-2 signaling pathways in vivo. The aim of this study was to determine whether blockade of PAR-2 by RNA interference influences pancreatic tumor growth. We originally constructed small interfering RNAs (siRNAs) targeting human PAR-2, and performed cell proliferation assays of Panc1 human pancreatic cancer cell line with these siRNAs. Intratumoral treatment with these PAR-2 siRNAs and atelocollagen was also performed in a xenograft model with nude mice and Panc1 cells. siRNAs against human PAR-2 inhibited proliferation of Panc1 cells, whereas control scramble siRNAs had no effect on proliferation. The PAR-2 siRNAs dramatically suppressed tumor growth in the xenograft model. PAR-2-specific siRNA inhibited growth of human pancreatic cancer cells both in vitro and in vivo. Blockade of PAR-2 signaling by siRNA may be a novel strategy to treat pancreatic cancer.

Adenomyomatous hyperplasia of the common bile duct: report of a case

Adenomyomatous hyperplasia is most commonly found in the stomach, gallbladder, duodenum, and jejunum, while it is rarely found in the extrahepatic bile duct. A 62-year-old woman was referred to our institution with a diagnosis of common bile duct (CBD) stenosis which had been detected by endoscopic retrograde cholangiopancreatography (ERCP). Abdominal computed tomography with contrast medium revealed a thickening of the wall of the lower CBD, and this lesion was weakly enhanced by contrast medium in the arterial phase. ERCP revealed a 15-mm-long stenosis of the lower CBD, but no malignant cells were detected by either bile cytology or brush cytology. Because CBD cancer could not be ruled out, pylorus-preserving pancreatoduodenectomy was performed. Histopathologically, multiple hyperplastic glands without cellular atypia were present in the lower CBD wall. An immunohistochemical study showed fibroblasts with positive staining for alpha-smooth muscle actin surrounding the glands. The lesion was diagnosed to be adenomyomatous hyperplasia of the CBD. When a diagnosis of adenomyomatous hyperplasia of the CBD is difficult to make both preoperatively and intraoperatively, then a radical surgical procedure, such as a pancreatoduodenectomy, may be an effective treatment alternative.

Hepatitis B virus infection predicts extrahepatic metastasis after hepatic resection in patients with large hepatocellular carcinoma

BACKGROUND

Although extrahepatic metastasis occurs rarely after hepatic resection for hepatocellular carcinoma (HCC), the prognosis of these patients is extremely poor. Predictors of extrahepatic metastasis have not been fully investigated.

METHODS

To identify predictors of extrahepatic metastasis after resection, we retrospectively investigated 77 patients with HCC tumors > 50 mm in diameter who underwent hepatic resection. We investigated correlations between postoperative extrahepatic metastasis and clinicopathologic factors as well as extrahepatic metastasis-free survival rate by log rank test and predictors of extrahepatic metastasis by univariate and multivariate logistic regression models.

RESULTS

Hepatitis B surface antigen (HBs-Ag) was found in 25 (32.5%) of 77 patients, and extrahepatic metastasis occurred in 26 (33.8%). Patients with extrahepatic metastasis showed better liver function and a high occurrence of HBs-Ag positivity than those without. The 5-year extrahepatic metastasis-free survival rate was worse in patients with HBs-Ag positivity, larger tumors (> or = 70 mm), higher alfa-fetoprotein level (> or = 300 ng/mL), and lower indocyanine green retention rate at 15 minutes (ICGR15) (< 15%) than in those without. By univariate logistic regression analysis, HBs-Ag positivity, larger HCC tumor (> or = 70 mm), lower ICGR15 (< 15%), and lower preoperative lymphocyte count (< 1000/mm3) were predictors of extrahepatic metastasis (P < .1). By multivariate analysis, HBs-Ag positivity was an independent predictor of postoperative extrahepatic metastasis (P = .04).

CONCLUSIONS

In patients positive for HBs-Ag, radiologic examination of extrahepatic organs should be performed as a part of the postoperative surveillance. Hepatitis B virus infection may promote establishment of extrahepatic metastasis.

Prophylactic fresh frozen plasma may prevent development of hepatic VOD after stem cell transplantation via ADAMTS13-mediated restoration of von Willebrand factor plasma levels

We initially conducted a multicenter, randomized trial (n=43), and subsequently a questionnaire study (n=209) of participating hospitals, to evaluate whether infused fresh frozen plasma (FFP) could prevent the occurrence of hepatic veno-occlusive disease (VOD) after stem cell transplantation (SCT). Forty-three patients were divided into two groups: 23 receiving FFP infusions and 20 not receiving it. VOD developed in three patients not receiving FFP. Plasma von Willebrand factor (VWF) antigen levels were lower at days 0, 7 and 28 after SCT in patients receiving FFP than in those not receiving it, whereas plasma ADAMTS13 activity (ADAMTS13:AC) did not differ between them. Plasma VWF multimer (VWFM) was demonstrated to be defective in the high approximately intermediate VWFM during the early post-SCT phase, but there was a significant increase in high VWFM just before VOD onset. This suggests that a relative enzyme-to-substrate (ADAMTS13/high-VWFM) imbalance is involved in the pathogenesis of VOD. To strengthen this hypothesis, the incidence of VOD was apparently lower in patients receiving FFP infusions than in those not receiving it (0/23 vs 3/20) in the randomized trial. Further, the results combined with the subsequent questionnaire study (0/36 vs 11/173) clearly showed the incidence to be statistically significant (0/59 vs 14/193, P=0.033).

An Obese Rat Model of Bariatric Surgery with Gastric Banding

BACKGROUND

Bariatric surgery is the only treatment that can provide effective long-term weight loss for morbid obesity. However, animal models of bariatric surgery have not yet been well established. The aims of this study were to establish an obese rat model of gastric banding and to determine whether the model would replicate the procedure of human gastric banding in terms of weight loss and metabolic parameters.

METHODS

27 male Zucker fatty rats were divided into 3 groups: the sham-operated control, gastric banding, and diet treatment groups. They were followed for 8 weeks after surgery, and their body weight change, cumulative food intake and metabolic parameters were examined.

RESULTS

For the sham-operated control, gastric banding, and diet treatment groups, the mean body weights were 644 +/- 28 g, 511 +/- 77 g, and 339 +/- 15 g; % change of weight at 8 weeks after operaion were +63.7 +/- 8.3%, +33.2 +/- 20%, -12.0 +/- 2.0%, respectively. Absolute weekly food intake amounts were 233.8 +/- 38.1 g, 157.3 +/- 64 g, 80 g, and cumulative food intakes were 1862 +/- 111 g, 1258 +/- 375 g and 640 g, respectively. The gastric banding rats showed significant decreases in weight gain, % change of weight, absolute weekly food intake, and cumulative food intake compared to sham-operated control rats (P < 0.05). The banding group also had lower levels of all metabolic parameters compared with controls (P < 0.01), and these levels were equal to those of the diet-treated group.

CONCLUSION

The present study provides a new animal model of gastric banding using obese rats. This model may be useful in research on the biochemical and molecular mechanisms of morbid obesity.

[Anti-tumor effects of various interferons-alpha +5-fluorouracil via downregulation of dihydropyrimidine dehydrogenase in hepatoma cells]

BACKGROUND AND AIMS

Systemic chemotherapy has not seen widespread use in the treatment for hepatocellular carcinoma (HCC). Recently, it was reported that combination treatment of 5-fluorouracil (5-FU) and interferon (IFN)-alpha was effective for non-resectable HCC. The effect of 5-FU treatment is influenced by the activities of pyrimidine catabolic enzymes. The aim of this study was to investigate which IFN-alphais most effective in combination therapy via downregulation of dihydropyrimidine dehydrogenase (DPD).

METHODS

Cell proliferation assay in human hepatoma cells (HepG 2) was performed using 5-FU and/or various IFNs-alpha (C-IFN, Intron A, OIF). At the same time,DPD mRNA levels were quantified by real-time polymerase chain reaction.

RESULTS

5-FU alone but not all the IFNs showed anti-cancer effects, and the combination of each IFN +5-FU had a greater anti-cancer effect than 5-FU alone. C-IFN +5-FU most effectively prevented cancer cell proliferation (p < 0.05). Also, the combination of C-IFN +5-FU most downregulated DPD mRNA expression.

CONCLUSION

The combination of each IFN-alpha +5-FU showed anti-cancer effects for HCC via downregulation of DPD. C-IFN may be most effective in the combination therapy of IFN-alpha +5-FU for HCC.

Prognostic value of preoperative peripheral blood monocyte count in patients with colorectal liver metastasis after liver resection

Prognostic values of leukocyte subset counts in peripheral blood of cancer patients have not yet been fully investigated. We retrospectively examined the relation between preoperative absolute counts of peripheral blood leukocyte subsets and clinicopathologic factors and long-term prognosis in 97 patients with liver metastasis from colorectal cancer who underwent hepatic resection. Median preoperative peripheral blood leukocyte subset counts were as follows: neutrophils 3148/mm3; lymphocytes 1574/mm3; monocytes 380/mm3. Univariate analysis indicated significantly worse 5-year cancer-related survival for patients with a peripheral blood monocyte count >300/mm3 (67.5%) than for patients with a count <or=300/mm3 (36.8%). Multivariate analysis showed a preoperative peripheral blood monocyte count >300/mm3 and preoperative CEA level (>10 ng/ml) to be independent predictive factors for cancer-related survival after hepatic resection. The preoperative peripheral monocyte count correlated positively with white blood cell and neutrophil counts, but not with the tumor number, interval between colorectal and hepatic surgery, or preoperative serum CEA level. Our findings indicate that a preoperative absolute peripheral blood monocyte count >300/mm3 is an independent predictive factor for cancer-related survival of patients with colorectal liver metastasis who have undergone hepatic resection.

Increased mRNA expression of chemokines in hepatocellular carcinoma with tumor-infiltrating lymphocytes

BACKGROUND

The infiltration of lymphocytes in tumor tissue has been associated with a good prognosis for patients with hepatocellular carcinoma (HCC). The purpose of the present study was to estimate the correlation between mRNA expression of chemokines and tumor-infiltrating lymphocytes in HCC.

METHODS

A total of 44 HCC were examined. Immunohistochemical staining was performed using antibodies to CD4, CD8, CD68, and L-26. The mRNA expression of each chemokine was investigated: regulated upon activation normal T-cell expressed and secreted (RANTES), interleukin-8 (IL-8), epithelial-derived neutrophil attractant-78 (ENA78), interferon-inducible protein-10 (IP-10), monokine induced by interferon-gamma (Mig), and interferon-gamma in HCC were quantified via a real-time polymerase chain reaction assay. Chemokine proteins of Mig and IP-10 were examined by immunohistochemistry.

RESULTS

The mean number of infiltrating lymphocytes in HCC was 136.9 +/- 32.9/0.25 mm2. Of these infiltrating lymphocytes, CD8-positive T lymphocytes were those predominantly seen around the tumor cells. The mean mRNA expression (copies/10(3) glyceraldehyde-3-phosphate dehydrogenase [GAPDH] mRNA) of the following chemokines was determined to be follows: 3.0 +/- 1.9 copies/10(3) GAPDH mRNA, RANTES; 9.2 +/- 4.9 copies/10(3) GAPDH mRNA, IL-8; 44.6 +/- 24.4 copies/10(3) GAPDH mRNA, ENA78; 215.7 +/- 93.9 copies/10(3) GAPDH mRNA, IP-10; 77.3 +/- 38.5 copies/10(3) GAPDH mRNA, Mig; and 1.7 +/- 0.4 copies/10(3) GAPDH mRNA, interferon-gamma. Significant close correlations were observed between the number of infiltrating lymphocytes in these HCC and the expression of Mig and IP-10 mRNA. In the immunostaining, expression of Mig and IP-10 proteins was found only in the HCC cells in the high-infiltration group.

CONCLUSIONS

Some chemokines induced by interferon-gamma, such as Mig and IP-10, may promote lymphocyte recruitment to HCC and may thus play important roles in cancer immunology.

Prognosis and postoperative lymphocyte count in patients with hepatocellular carcinoma who received intraoperative allogenic blood transfusion: a retrospective study

AIMS

The effect of perioperative blood transfusion on the survival of hepatocellular carcinoma (HCC) has not been fully investigated. To clarify the prognostic value of intraoperative allogenic blood transfusion, we conducted a comparative retrospective analysis of 224 patients with HCC who underwent hepatic resection.

METHODS

We compared clinicopathologic background and survival after hepatic resection between patients who received intraoperative blood transfusion (n=101) and those who did not (n=123).

RESULTS

Patients with blood transfusion had a larger tumor and more frequent vascular invasion than those without blood transfusion. The 5-year cancer-related survival rate after hepatic resection, but not the disease-free survival rate, was significantly lower in patients who underwent blood transfusion than in those who did not (38.3% vs. 66.7%, P<0.01). Multivariate analysis showed intraoperative blood transfusion (P=0.02), microscopic portal invasion (P<0.01), and preoperative serum alpha-fetoprotein elevation (P=0.03) to be independent risk factors for poor outcome after hepatic resection. The negative effect of blood transfusion on postoperative survival was observed only in patients with a tumor larger than 50mm in diameter. The absolute peripheral blood lymphocyte count on postoperative day 1 was significantly lower in patients who underwent blood transfusion (880/mm(3)) than in those who did not (1081/mm(3)) (P<0.01).

CONCLUSIONS

Our data suggest that intraoperative blood transfusion results in immunosuppression in the early postoperative period, allowing for progression of residual HCC after resection. Therefore, intraoperative allogenic blood transfusion should be avoided in patients with resectable HCC, particularly in those with a large tumor.

Prominent hepatic encephalopathy 19 years after splenopneumopexy in Budd-Chiari syndrome

Splenopneumopexy, which was developed in Japan, has been recognized as an effective surgical procedure in patients with Budd-Chiari syndrome. We report the case of a 72-year-old woman with Budd-Chiari syndrome and prominent hepatic encephalopathy. She was treated by splenopneumopexy 19 years previously at our institute. Recently, during a follow-up visit, she experienced disorientation and unconsciousness. Flapping tremor was also recognized, and electroencephalography demonstrated a triphasic wave. In computed tomography and angiography imagings, the inferior vena cava was obstructed and the portopulmonary shunt placed by splenopneumopexy was remarkably dilated. There were no other major collaterals of the portal venous system. These findings showed that the hepatic encephalopathy was caused by the change in the portopulmonary shunt. Because hepatic encephalopathy can appear after splenopneumopexy, long-term follow-up may be necessary in patients with Budd-Chiari syndrome who are treated by splenopneumopexy.