Shin-ichi Iwamoto

Hemostasis activation during sclerotherapy of lower extremity varices

The influence of compression sclerotherapy upon hemostasis activation was investigated in 41 consecutive patients with lower extremity varices by serial measurement of thrombin-antithrombin III complexes (TAT), D-dimer, fibrinogen and C-reactive protein (CRP). Blood sampling was carried out before operation and on the 7th and 28th post-operative day in patients randomly assigned to either the control group (n = 18), in which high ligation of sapheno-femoral junction and local excision of varices were performed, or the sclerotherapy group (n = 23) in which the comparable surgical intervention and compression sclerotherapy using hypertonic saline were performed simultaneously. In both groups, the TAT, D-dimer and fibrinogen concentrations at day 7 were significantly elevated compared to the value before operation while CRP showed no significant change during the observation period. In the sclerotherapy group, higher incidence of superficial thrombosis was observed and the TAT concentration at day 7 was significantly higher than that in the control group (p < 0.01), and the TAT at day 28 was still significantly elevated compared to the pre-operative level (p < 0.05). However, no relationship between TAT and D-dimer concentrations and the extent of superficial thrombosis was observed. We conclude that compression sclerotherapy for lower extremity varices causes latent activation of coagulation system and can be a risk factor for venous thromboembolism.

The coagulofibrinolytic state of patients with primary varicose veins of the lower legs.

The relationship between a local hypercoagulable state and primary varicose veins of the lower legs was investigated by measuring the plasma levels of D-dimer (DD) and the thrombin-antithrombin-III complex (TAT) in 122 consecutive patients before treatment, and in 46 patients after surgical intervention and compression sclerotherapy. Elevated levels of DD and TAT were found in 25% and 20%, respectively, of the 122 patients, being significantly elevated in the patients with thrombophlebitis compared to the patients with no dermal symptoms, pigmentation, or stasis dermatitis. There was no significant difference in either parameter among eight groups of patients classified according to their valvular incompetence. The levels of DD and TAT were elevated before treatment in 25% and 20%, respectively, of 45 treated patients, but became significantly reduced after treatment. These results indicate that even though the local hypercoagulable state in varicose veins without thrombophlebitis is too subtle to be detected by systemic parameters such as DD and TAT, a local hypercoagulable state can be detected in a certain proportion of patients with venous stasis by these parameters.

Diagnostic value of plasma thrombin-antithrombin III complex and D-dimer concentration in patients with varicose veins for exclusion of deep-vein thrombosis

The aim of this study was to evaluate the usefulness of determining plasma D-dimer (DD) and thrombin-antithrombin III complex (TAT) levels in the diagnostic workup for the screening of deep-venous thrombosis (DVT) among varicose vein patients. One hundred forty consecutive patients being treated for DVT or varicose veins underwent color-flow duplex scanning, and 25 patients had DVT and the remaining 115 had primary varicose veins. When DD and TAT were analyzed statistically in combination, it was determined that the combination of either positive DD (cutoff level 1.0 microg/ml) or positive TAT (cutoff level 3.0 microg/l) had a sensitivity of 100% for DVT with a specificity, positive predictive value, and negative predictive value of 79%, 51%, and 100%, respectively. This study demonstrates plasma levels of DD (less than 1.0 microg/ml) and TAT (less than 3.0 microg/l) in combination to be useful for the exclusion of DVT among patients with varicose veins. Patients with negative hematological data may safely undergo surgical treatment for varicose veins without further evaluation such as duplex scanning or contrast venography.

Sclerotherapy for varicose veins of the lower legs in patients with dysplasminogenemia.

Sclerotherapy combined with ligation has become a widely accepted treatment for varicose veins; however, it is associated with some risk of the serous complications of deep vein thrombosis (DVT). We investigated the incidence of thrombophilia in 164 consecutive patients undergoing treatment for varicose veins and determined the activities of antithrombin-III, protein C, and plasminogen. Of the 164 patients, 10 were diagnosed as having dysplasminogenemia (DPG), showing an incidence of 6.1%, in accordance with previous reports. DVT was not found to be caused by DPG in any patient, and no difference was found between patients with and those without DPG, suggesting that DPG is not a risk factor for varicose veins. We also investigated the activation of coagulation by measuring the thrombin-antithrombin III complex (TAT). The activation of coagulation after sclerotherapy was inhibited when ligation was performed 1 month prior to sclerotherapy, whereas it was increased when sclerotherapy and ligation were performed simultaneously. Of the 10 patients with DPG, 5 were treated uneventfully, and their TAT level increased to 4.0 μg/l, which was comparable to the level after sclerotherapy and ligation. These findings indicate that sclerotherapy can be performed safely in the majority of patients with DPG, and that the temporal separation of sclerotherapy and surgery is an alternative for these patients to prevent the activation of coagulation.

Solitary Tuberculoma of the Liver Concomitantly Found in a Pancreatic Cancer Patient.

孤立性肝結核腫は比較的まれな疾患であり, 肉芽腫を主体とするものは, 自験例を加えても本邦報告例は25例にすぎない. 著者らが最近経験した1切除例を本邦報告例の検討とあわせて報告する. 症例は77歳の男性で, S状結腸癌術後の経過観察中にCA19-9値の上昇が見られた. 腹部CT, エコー, ERCPおよび血管造影所見より, 膵体部癌とS6肝転移が疑われた. 膵体尾部切除およびS6肝部分切除を施行したが, 肝腫瘤部は, 病理組織学的には乾酪壊死巣と間質へのリンパ球浸潤および類上皮細胞が認められ, 肝結核腫と診断された. 孤立性肝結核腫はまれであるものの, 肝腫瘍の鑑別診断に際し留意すべき疾患であると考えられる.

The Significance of Hepatectomy for Stage IV Hepatocellular Carcinoma.

1990年12月31日末までの当センターにおける肝細胞癌 (hepatocellular carcinoma; HCC) に対する肝切除術施行例は291例でそのうちStage IV症例は38例であった.これら38例についてその予後からみた肝切除術の適応と意義について考察した.StageIV全症例の5年生存率は19%で, StageI, II, IIIに比べ有意に不良であった.しかしながら相対非治癒 (relative noncurative, RN) 切除症例17例の5年生存率は40%と他Stageの絶対非治癒 (absolute noncurative, AN) 切除を除いた症例の5生率と有意差はなかった.これらの症例はStageIVの絶対非治癒 (AN) 切除例に比べ腫瘍因子において有意に良好であった.特に腫瘍数が2個で多中心性発癌の可能性が考えられた症例に対する切除成績は極めて良好であった, これよりStage IV症例であってもRNの手術可能な場合は施行すべきであると考えられた.一方, AN症例については2年以上生存例はなく手術適応になるとはいい難いが, 手術後にtranscatheter arterial embolization (TAE) を主体とした集学的治療を施行することを前提とした補助的外科療法としての意義を見いだしうる可能性が考えられた.