Katsuji Sakai

Preoperative portal vein embolization for hepatocellular carcinoma

Advances in diagnostic imaging and new surgical techniques have improved the outcome for many patients with hepatocellular carcinoma (HCC). However, in Japan, more than 70% of patients with HCC have cirrhosis of the liver [1], and resection of the liver of such patients is often limited by the cirrhosis. Therefore, nonsurgical treatments such as transcatheter arterial embolization (TAE) or percutaneous ethanol injection therapy have been developed and are used widely as adjuvant therapy. TAE was first used to treat HCC patients by Goldstein et al. [2], who reasoned that most of the blood flow to the tumor is supplied by the hepatic artery. However, according to a study by the Liver Cancer Study Group of Japan [3], TAE is effective against the main tumor, but not against small intrahepatic metastases or tumor thrombi; it is particularly ineffective against tumor thrombi.

The relation between carcinoma of the gallbladder and an anomalous connection between the choledochus and the pancreatic duct.

An anomalous connection between the choledochus and the pancreatic duct may be associated etiologically or pathogenetically with congenital biliary dilation and carcinoma of the dilated bile duct. During the past 10 years, a total of 14 cases of carcinoma of the gallbladder with an anomalous connection between the choledochus and the pancreatic duct were encountered. These cases were studied in reference to their clinical features and histological findings. An experimental model of pancreatic juice inflow into the gallbladder of mongrel dogs was produced and the histological changes of the mucosa of that organ was observed. The intent was to elucidate the relationship between carcinoma of the gallbladder and this anomaly. The results of this clinical and experimental study suggest that reflux and stasis of pancreatic juice in the gallbladder induce chronic cholecystitis with intestinal metaplasia. This may be important in the pathogenesis of well-differentiated carcinoma of the gallbladder.

Carcinoma of the gallbladder with an anomalous connection between the choledochus and the pancreatic duct. Report of 10 cases and review of the literature in Japan.

During the last 8 years, the authors had experience with 10 cases of carcinoma of the gallbladder with an anomalous connection between the choledochus and the pancreatic duct. These cases were studied in reference to age, sex, frequency of gallstones and dilatation of the bile duct, amylase levels in bile, direct cholangiograms, histologic findings, methods of treatment, and prognosis. Histologically, intestinal metaplasia was noticed in cancerous areas and also in noncancerous areas of differentiated adenocarcinomas. These facts suggest that in carcinoma of the gallbladder with this anomaly, reflux and stasis of pancreatic juice in the gallbladder may induce chronic cholecystitis which leads to mucosal metaplasia and, eventually, to differentiated adenocarcinoma.

Esophagoplasty with an autogenous tubed gastric flap.

As an esophageal substitute, a tubed gastric flap 2.5 cm in inner diameter and 38 cm in length, was constructed from the gastric wall along the greater curvature; a pedicle was attached to the gastric antrum, and its oral stump was brought up into the left supraclavicular fossa through a retrosternal tunnel to perform an esophagogastrostomy. Anastomotic breakdown occurred in only three of fifty cases in which this procedure was used.

Effect of portal branch ligation on polyamine metabolism in rat liver

The activity of ornithine decarboxylase and the intracellular concentrations of putrescine and spermidine in the non-ligated lobes of the liver increased after portal branch ligation. These changes were followed by increased [3H]thymidine uptake into the acid-insoluble fraction of the liver. The induction of ornithine decarboxylase and changes in intracellular polyamines are important biochemical events in liver regeneration, so our results suggest that portal branch ligation causes formation of some stimuli that trigger liver regeneration. Changes were less with ligation than with partial hepatectomy.

Effect of splenectomy on liver regeneration and polyamine metabolism after partial hepatectomy

The effect of splenectomy on hepatic ornithine decarboxylase (ODC) induction, DNA synthesis, and mitosis of hepatocytes was studied in rat liver after partial hepatectomy. ODC activity markedly increased in the early stages of liver regeneration, and the increase in the activity was significantly enhanced in splenectomized rats. Splenectomy specifically induced ODC since tyrosine aminotransferase and general protein synthesis were not affected. Splenectomy also enhanced increase in hepatic polyamines, DNA synthesis, and mitosis in regenerating liver. The results suggest that splenectomy affects liver regeneration after partial hepatectomy by enhancing induction of ODC activity, which is an important biochemical event in the early stage of liver regeneration.

Measurement of human portal blood flow by continuous thermodilution

We wanted to use the Ganz thermistor catheter, developed to measure blood flow in human coronary sinuses, to measure portal venous flow, which is greater. We prepared a model circuit with a high flow rate and studied the method for suitability and reproducibility of the measurements. Correlation was close between the measured and calculated flow rates when the thermal indicator was injected at the rate of 48 ml/min. Measurements were highly reproducible. The catheter was then tested clinically. It was inserted into the portal trunk during percutaneous transhepatic catheterization to measure the portal venous flow. Measurements in patients with cirrhosis of the liver were close to those reported by other workers, and were reproducible. The results suggest that this method will be useful for the continuous local measurement of portal venous flow that varies with time, and will provide information about portal circulation in hepatic disease.

Surgical management of renal cell carcinoma with inferior vena caval and right atrial involvement

A 52-year old man underwent successful surgical removal of renal cell carcinoma with inferior vena caval and right atrial involvement, under cardio-pulmonary bypass. The postoperative progress was uneventful and at this writing he is doing well, with no evidence of metastasis.

Preoperative Staging of Esophageal Cancer by Endoscopic Ultrasonography

Preoperative assessment of the depth of tumor invasion in patients with esophageal cancer is of vital importance for ensuring completeness of excision. It is also useful for making a precise diagnosis of metastasis to the mediastinal lymph nodes and determining the range of mediastinal dissection, which affects postoperative pulmonary complications. In the present study we investigated the diagnostic value of endoscopic ultrasonography in assessing the extent of cancer invasion and detecting lymphatic metastasis in esophageal cancer.

Studies of cefotaxime serum concentrations during surgery under general anaesthesia and its passage to the wound fluid after surgery for breast cancer

SummaryWe are reporting on a comparison of serum concentrations of cefotaxime during and after surgery and on its passage to the wound fluid after surgery. Five patients undergoing mastectomy and dissection of the axillary lymph nodes for breast cancer were studied. Serum concentrations were compared after 2 g of cefotaxime dissolved in 20 ml of saline had been administered by i.v. bolus injection intraoperatively during general anaesthesia and six to eight days postoperatively in a conscious state. After intraoperative administration under general anaesthesia, cefotaxime serum concentrations were 157.3 mg/l at 15 min, 87.5 mg/l at 30 min, 43.08 mg/l at 1 h, 15.54 mg/l at 2 h and 9.56 mg/l at 3 h. In a conscious state, cefotaxime serum concentrations were 122.0 mg/l at 15 min, 84.35 mg/l at 30 min, 47.63 mg/l at 1 h, 18.2 mg/l at 2 h and 9.63 mg/l at 3 h, comparable to the time course under general anaesthesia. The half-life of cefotaxime was 0.86 h under general anaesthesia and 0.92 h in a conscious state. Urinary recovery of cefotaxime (0 to 3 h) under anaesthesia and in a conscious state was 53.8% and 56.3%, respectively (as reported previously for a non-surgical state). Samples of wound fluid were taken at the completion of surgery from the drain inserted subcutaneously into the wound or by means of a tracheal aspirator kit attached to a portable aspirator. Cefotaxime concentrations were determined postoperatively on days six to eight, when the wound fluid became no longer serous. The mean wound fluid concentration of cefotaxime was 5.53 mg/l after 2 h, 16.7 mg/l (peak) after 3 h, 14.65 mg/l after 4 h, 12.25 mg/l after 5 h and 7.9 mg/l after 6 h. Similar studies with other cephalosporins will also be mentioned for comparison.ZusammenfassungWir berichten über Serumkonzentrationen von Cefotaxim während und nach chirurgischen Eingriffen und seine Penetration in Wundsekret nach Mammakarzinom-Operation. Fünf Patientinnen, bei denen eine Mastektomie mit Lymphknoten-Dissektion durchgeführt wurde, erhielten 2 g Cefotaxim in 20 ml physiologischer Kochsalzlösung durch i.v. Bolusinjektion während der Operation unter Allgemeinanästhesie und postoperativ am sechsten bis achten Tag in wachem Zustand. Die in der jeweiligen Untersuchung bestimmten Serumspiegel betrugen unter Allgemeinnarkose nach 15 min 157,3 mg/l, nach 30 min 87,5 mg/l, nach 1 h 43,08 mg/l, nach 2 h 15,54 mg/l und nach 3 h 9,56 mg/l. Im wachen Zustand wurden entsprechend 15 min nach Injektion 122,0 mg/l, nach 30 min 84,35 mg/l, nach 1 h 47,63 mg/l, nach 2 h 18,2 mg/l und nach 3 h 9,63 mg/l gemessen. Die Halbwertszeit von Cefotaxim unter Allgemeinnarkose betrug 0,86 h und im wachen Zustand 0,92 h. Die Harnrecovery von Cefotaxim im Zeitraum 0 bis 3 h nach Applikation betrug unter Narkose 53,8% und im wachen Zustand (entsprechend früheren Mitteilungen bei nichtchirurgischen Patienten) 56,3%. Nach der Operation wurde aus dem subkutanen Drain durch ein tragbares Absaugegerät (mit Absaugvorrichtung für Trachealsekret) Wundsekret gewonnen. Die Cefotaximkonzentrationen wurden am sechsten bis achten postoperativen Tag, wo das Wundsekret nicht mehr mit Serum identisch war, bestimmt. Die Wundsekretkonzentration betrug im Mittel nach 2 h 5,53 mg/l, nach 3 h 16,7 mg/l (Spitzenwert), nach 4 h 14,65 mg/l, nach 5 h 12,25 mg/l und nach 6 h 7,9 mg/l. Zum Vergleich werden ähnliche Studien mit anderen Cephalosporinen dargestellt.