Shuji Matsubara

Continuous removal of middle molecules by hemofiltration in patients with acute liver failure.

In patients with acute liver failure and hepatic coma, an increase in the abnormal “middle molecules” seen on the chromatograms of the sera is suspected of playing an etiologic role in the coma. A pilot study of continuous hemofiltration using a high-performance membrane was conducted in 16 such patients in an attempt to decrease the serum levels of the middle molecules. The procedure was used alternately with plasma exchange. High-performance liquid chromatography showed a notable removal of the substances in the filtrates and a sequential removal from the serum by hemofiltration. Eight (50%) of the 16 patients had amelioration in level of consciousness and were weaned successfully from hemofiltration. Although only three of the 16 patients survived the acute illness, 13 others lived an average of 15 days and five patients survived >3 wk. While the continuous removal of middle molecules from the serum may not reverse liver failure, this procedure used in conjunction with plasma exchange may provide a means of life support, e.g., for patients awaiting a liver transplant.

Recurrence of hepatocellular carcinoma in the liver remnant after hepatic resection

We analyzed the results of 19 patients who had intrahepatic recurrence of hepatocellular carcinoma (HCC) among 47 patients who were discharged from the hospital after having a hepatic resection in order to evaluate the factors affecting recurrence and survival. Recurrence-free survival rates were 80%, 44%, and 28% at 1, 3, and 5 years, respectively. Of the 19 patients with recurrence, 14 had multiple lesions, and 16 of the recurrences were detected within 3 years of surgery. None of the following factors correlated with recurrence: hepatic function; tumor size; presence of tumor capsule; capsular invasion; vascular invasion and intrahepatic metastasis; extent of hepatic resection; and resection with tumor-free margins. Patients having multiple recurrent HCCs, however, had larger-sized tumors at the time of resection than those with a solitary recurrence. The survival rates after recurrence were significantly better in patients with a solitary recurrence, and these patients were treated with transcatheter arterial embolization (TAE) therapy. Early detection as well as TAE for recurrent HCCs is necessary to improve long-term survival.

Portal Venous Pressure following Splenectomy in Patients with Portal Hypertension of Differing Etiology

To clarify the effect of splenomegaly on portal hemodynamics in patients with portal hypertension and esophageal varices, manometric studies were carried out before and after splenectomy during an operation for esophageal varices. The 118 patients evaluated retrospectively had underlying liver cirrhosis (LC) (62), idiopathic portal hypertension (IPH) (42), and extrahepatic portal occlusion (EHO) (14). The weight of the spleen did not differ significantly among the three diagnostic groups: 640 +/- 473.5 g for LC, 780 +/- 414.6 g for IPH, and 683 +/- 457.2 g for EHO. Before splenectomy, portal pressure was significantly elevated in the patients with EHO (410 +/- 85.2 mm H2O) as compared to either the LC or IPH groups (348 +/- 64.1 and 348 +/- 73.5 mm H2O). Following splenectomy the reduction of portal pressure was significantly greater in the EHO group (29 +/- 15.5%) than in either the LC (18 +/- 17.4%) or IPH (19 +/- 17.0%) groups. Each group was subdivided according to severity of splenomegaly: marked (spleen weight > or = 500 g) or slight (spleen weight < 500 g). Patients with LC and marked splenomegaly showed a reduction in liver function parameters as shown by the prolongation of indocyanine retention rate at 15 min as compared to those with slight splenomegaly. Though it is not statistically significant, the average portal pressure tended to be higher among those with marked splenomegaly.(ABSTRACT TRUNCATED AT 250 WORDS)

Increased Hepatic Phosphatidylcholine Hydroperoxide and Deteriorated Hepatic Energy Metabolism in Rats with Endotoxemia

Liver dysfunction has been observed during severe nonhepatic infection with gram-negative bacteria; however, the pathogenesis of this clinical manifestation remains obscure. This study was designed to see the effect of endotoxemia on the oxidation product of one of the major classes of lipids associated with hepatocellular membrane, i.e. hepatic phosphatidylcholine hydroperoxide (PCOOH). The relations between PCOOH, hepatic energy charge and hepatic blood flow were also investigated. Cecal ligation and puncture (CLP) for the induction of endotoxemia were performed in rats. Compared to levels before CLP the serum endotoxin and hepatic PCOOH increased significantly (p

Perioperative Blood Loss Is a Major Risk Factor for Nonshunt Celiotomies in Patients with Liver Cirrhosis - Clinical and Experimental Evidence

The records of 76 consecutive cirrhotic patients undergoing nonshunt celiotomy were reviewed. Hospital mortality was 14.5%, and emergent operations were more frequent in nonsurvivors than survivors (p

Evaluation of prognostic factors of primary hepatocellular carcinoma after hepatectomy: 10 years' experience

In order to elucidate both short- and long-term prognostic factors, 54 patients with hepatocellular carcinoma who underwent hepatic resection in the past 10 years were studied. In the analysis of fact

Factors Affecting Long-Term Survival and Recurrence of Hepatocellular Carcinoma (HCC) After Hepatic Resection

In order to elucidate prognostic factors affecting long-term survival and intrahepatic tumor recurrence, 56 patients with HCC who underwent hepatic resection in the past 10 years were studied. The actual survival rate of the patients excluding 9 hospital deaths was 65% at 3 years, and 43% at 5 years. Prothrombin time and size of tumor were the decisive factors that affected long-term prognosis. Nineteen patients had intrahepatic recurrence of HCC among 47 patients who were discharged from the hospital. Of the 19 patients with recurrence, 14 had multiple lesions, and 16 of the recurrences were detected within 3 years of surgery. Patients having multiple recurrent HCCs had larger sized tumors at the time of resection than those with a solitary recurrence. The survival rates after recurrence were significantly better in patients with a solitary recurrence, and those treated with transcatheter arterial embolization therapy (TAE). Hepatic resection for patients with functionally well-preserved livers, bearing small tumors correlates with long-term survival. Early detection as well as TAE for recurrent HCCs is necessary to improve long-term survival.

Limitation of Non-Shunting Operation and Endoscopic Injection Sclerotherapy for Esophageal Varices and the Role of Combined Treatment

Formerly, the purpose of the non-shunting operation was to eradicate esophageal varices completely. Although most patients who received the complete operation of transthoracic esophageal transection and gastric devascularization (the Sugiura procedure) could achieve eradication of esophageal varices, patients who only received esophageal transection or gastric devascularization because of limited hepatic functional reserve showed a higher chance of residual or recurrent varices [1]. After induction of endoscopic injection sclerotherapy (EIS) treatment strategy for esophageal varices varied dramatically. Although some authors reported that EIS is more than palliative treatment for esophageal varices, some reported high incidence of re-bleeding following EIS [2, 3]. There may be a place for combined therapy employing non-shunting operation and EIS for the treatment of esophageal varices. Based on our clinical experience with 132 non-shunting operations and 80 EISs for esophageal varices due to liver cirrhosis, the significance of combined therapy of both methods was studied referring the limitation of those two kinds of treatment.

A Case of Hepatic Failure after Right Hepatic Lobectomy for Hepatocellular Carcinoma with Chronic Active Hepatitis.

術前肝機能検査にて肝硬変非併存肝癌と診断され肝右葉切除を施行し術後肝不全に陥った症例について報告する. 症例は59歳の男性でT.Bil0.5mg/dl, GOT48, GPT60IU/l, PT97.5%, ICG-R155.4%と良好な肝機能を呈したため肝右葉切除術を施行した. しかし術後早期より黄疸が出現し, 15回の血漿交換療法にもかかわらず第63病日に肝不全にて死亡した. 切除肝の非癌部は門脈域の細胞浸潤, 門脈域間のbridgingおよびpiecemealnecrosisを伴う慢性活動性肝炎であった. 術前の一般肝機能検査では診断しえず, 肝炎の活動性の評価には数か所にわたる肝生検が必要であると思われた.

Significance of Host Defense Mechanisms in Hepatoma Patients with Chronic Active Hepatitis Indicating for Hepatic Resection.

慢性活動性肝炎 (CAH) 併存肝細胞癌例では肝切除などの侵襲過大な手術によって術後肝不全を発症する可能性はきわめて高い.今回, 肝切除術後に順調に経過したCAH非併存の肝硬変6例 (1群) と肝切除術後に肝不全にて死亡したCAH併存の4例 (II群) とを対比し, 主に生体防御能を示す諸指標につき検討を加えた.網内系phagocytic index, オプソニン活性, CH50, フィブロネクチン, Leu11を測定したところ, それらの術後14日までの値はいずれも1群に比較してII群で有意の低値を示した.さらに術前のオプソニン活性 (I群97.2±3.7%: II群82.3±9.4%, p<0.01), CH50 (1群38.4±5.1u/ml: II群23.7±5.9u/ml, p<0.01) には両群間に有意の差を認め, これらが低下している症例では活動性の肝病変を合併している可能性を念頭におくべきと考えられた.以上, 生体防御能諸指標は手術適応および術式の決定, 予後の予測にきわめて重要な因子となりうる.