Taro Sakamoto

Negative impact of blood transfusion on recurrence and prognosis of hepatocellular carcinoma after hepatic resection.

BackgroundIn perioperative management of hepatic resection for hepatocellular carcinoma, excessive blood loss and blood transfusion greatly influence postoperative complications and prognosis of the patients. We evaluated the influence of blood products use on postoperative recurrence and prognosis of patients with hepatocellular carcinoma.MethodsThe subjects were 66 patients who underwent elective hepatic resection for hepatocellular carcinoma without concomitant microwave or radiofrequency ablation therapy nor other malignancies between January 2001 and June 2006. We retrospectively investigated the influence of the use of blood products including red cell concentration and fresh frozen plasma on recurrence of hepatocellular carcinoma and overall survival.ResultsIn multivariate analysis, the dose of blood products transfusion was a significant predictor of disease-free and overall survival. Both disease-free and overall survival rates of those who were given blood products were significantly worse than those who did not receive. On the other hand, in univariate analysis of disease-free and overall survival after hepatic resection and clinical variables, the amount of blood loss was not a significant predictor of recurrence or death.ConclusionTransfusion of blood products is associated with increased recurrence rate and worse survival after elective hepatic resection for patients with hepatocellular carcinoma.

Preoperative platelet to lymphocyte ratio predicts outcome of patients with pancreatic ductal adenocarcinoma after pancreatic resection

BACKGROUND Inflammation plays a crucial role in tumor growth, metastasis, and survival. The preoperative platelet-to-lymphocyte ratio (PLR) has been reported as a significant prognostic indicators in several digestive malignancies. Our objective was to evaluate whether preoperative PLR is a prognostic index in resected pancreatic ductal adenocarcinoma. METHODS Data from 131 patients who underwent pancreatic resection for pancreatic ductal adenocarcinoma were available from a prospectively maintained database. The patients were divided into groups according to a preoperative PLR of <150 or ≥150. Survival data were analyzed. RESULTS In univariate and multivariate analyses, a preoperative PLR of ≥150 was a significant and independent risk factor for cancer recurrence and poor survival, respectively (disease-free survival [DFS]; P= .0014, P = .047; OS, P ≤ .01each). Similarly, lymph node metastasis, and moderate or poor differentiation were independent risk factors for cancer recurrence, whereas tumor diameter, positive surgical margin, and moderate or poor differentiation were independent risk factors for poor patient survival (P ≤ .05 each). CONCLUSION The preoperative PLR in patients with pancreatic ductal adenocarcinoma was an independent predictor in DFS and overall survival after elective resection. Measurement of the PLR may help decision making in the postoperative management of patients with pancreatic ductal adenocarcinoma.

Minimizing intraoperative bleeding using a vessel‐sealing system and splenic hilum hanging maneuver in laparoscopic splenectomy

BACKGROUND/PURPOSE The most common cause of conversion to laparotomy (open splenectomy) during laparoscopic splenectomy (LS) is bleeding from the splenic hilar vessels. Recently, the efficacy of Ligasure (a vessel-sealing system) as a safety device for sealing vessels and reducing intraoperative blood loss has been reported with various laparoscopic procedures. The objective of this report was to describe our techniques for minimizing bleeding during LS, characterized by the application of Ligasure (which reduces the number of clips and staples, and reduces unnecessary bleeding) and a splenic hilum hanging maneuver with a Diamond-Flex flexible retractor to obtain optimal exposure of the splenic hilum. METHODS We have performed 87 LSs since February 1993, and have employed the Ligasure instead of metal clips and staplers since September 2003. We have also introduced the splenic hilum hanging maneuver paired with Ligasure use. We have performed this new LS in 30 consecutive adult patients presenting with idiopathic thrombocytopenic purpura (n = 14), benign splenic tumor (n = 5), lymphoma (n = 4), hereditary spherocytosis (n = 2), liver cirrhosis (n = 2), and other pathologies (n = 3). The splenic ligaments and vessels, including the splenic artery and vein, were divided using a 5-mm Ligasure instead of a clip or stapler. The splenic hilum was encircled and elevated, using a Diamond-Flex, to ensure better exposure in all patients. RESULTS LS was successfully completed in 29 patients (97%), with only one conversion to open splenectomy. Mean blood loss for all patients with completed LS was only 21.6 ml (range 0-250 ml). Moreover, blood loss was not determinable (considered as 0 ml in this study) in 15 patients (52%). Mean spleen weight and operating time were 319.4 g (range 80-1605 g) and 143.4 min (range 90-180 min), respectively. No postoperative mortalities were encountered. Two patients experienced complications, including grade B pancreatic fistula and atelectasis, for an overall morbidity rate of 6.7%. Mean postoperative stay was 6.5 days (range 3-14 days). CONCLUSIONS LS using a Ligasure in combination with the splenic hilum hanging maneuver may reduce intraoperative blood loss.

F2-Isoprostanes and 2-Arachidonylglycerol as Biomarkers of Lipid Peroxidation in Pigs with Hepatic Ischemia/Reperfusion Injury

BACKGROUND In the present study, we examined the changes of F(2)-isoprostanes (non-cyclooxygenase-derived prostanoids), endocannabinoids (2-arachidonylglycerol; 2-AG, arachidoylethanolamide; AEA), and malondialdehyde (MDA: a conventional index of lipid peroxidation) in a porcine warm hepatic ischemia/reperfusion (I/R) model to evaluate the usefulness of each parameter as a marker of lipid peroxidation. METHODS Five female pigs weighing 20 to 22 kg were used in this experiment. Total liver ischemia was achieved by clamping the hepatic pedicle. To prevent splanchnic congestion during occlusion of the portal vein, a portocaval shunt was created with a Dacron graft. After 90 min of ischemia, the liver was reperfused for 120 min. We measured the plasma levels of four markers (F(2)-isoprostanes, 2-AG, AEA, and MDA) from a viewpoint of whether it is useful as a sensitive marker of lipid peroxidation. RESULTS Based on statistical analysis using repeated-measures ANOVA, F(2)-isoprostanes demonstrated the most significant changes and were considered to be a highly sensitive marker (P = 0.0001). 2-AG showed less prominent but significant changes (P = 0.0286), followed by MDA (P = 0.0310). However, AEA did not show statistically significant changes over time. The pattern of change in the serum transaminase levels, a classic marker of liver damage, as well as the histologic changes, resembled the profile of F(2)-isoprostanes, 2-AG, and MDA. CONCLUSIONS F(2)-isoprostanes and 2-AG may be useful as markers of oxidative stress in hepatic I/R injury.

Acute tumor lysis syndrome after transarterial chemoembolization for hepatocellular carcinoma

A 77‐year‐old‐man was admitted to hospital for treatment of a huge hepatocellular carcinoma by transarterial chemoembolization. After treatment, the patient developed acute tumor lysis syndrome with hyperkalemia, hyperuricemia, hyperphosphatemia, hypocalcemia, metabolic acidosis and acute renal failure, which was successfully treated. In the treatments of solid organ tumors, acute tumor lysis syndrome is an extremely rare complication. To the best of the authors’ knowledge, this patient is the third case of such a complication after transarterial chemoembolization for a hepatocellular carcinoma in the English literature. (Cancer Sci 2008; 99: 2104–2105)

Anti-angiogenic Therapy on Hepatocellular Carcinoma Development and Progression

BACKGROUND The hypervascular nature of hepatocellular carcinoma (HCC) has led a number of investigators to explore the potential of anti-angiogenic therapy for this cancer. We aimed to investigate the efficacy of anti-angiogenetic therapy for the prevention and treatment of HCC. METHODS An experimental model of HCC induced by diethylnitrosamine (DEN) was used in this study as a model resembling human HCC. Because endothelial cells play a central role in angiogenesis, FR-118487 (FR) with a direct effect on endothelial cells was selected for use in this study. FR-treated rats were divided into three groups of five animals each according to the timing of FR treatment, i.e., at the initiation of exposure to DEN (group I), after 6 wk of DEN exposure (group II), and after 12 wk of DEN exposure (group III). RESULTS No macroscopic nodules were observed in group I. Moreover, no significant difference in the mean maximum diameter and number of HCC nodules were found between the control group at 12 wk and group III at 18 wk. Thus, FR was shown to have a chemopreventive effect in addition to causing dormancy of HCC. The results obtained, including IL-8 levels, reflected the effect on HCC of anti-angiogenic therapy with FR. CONCLUSION Anti-angiogenic therapy may be effective for both chemoprevention and tumor dormancy in HCC associated with chronic liver disease. IL-8 may be useful as a marker of the efficacy of anti-angiogenic therapy for HCC.

Proton-pump inhibitor as palliative care for chemotherapy-induced gastroesophageal reflux disease in pancreatic cancer patients.

Relief of adverse events induced by chemotherapy is an important issue for patients, especially those with a poor prognosis, such as with pancreatic cancer. There are no reports of the relationship between gastroesophageal reflux disease (GERD) and chemotherapy, so we investigated the incidence of chemotherapy-induced GERD in patients undergoing treatment with gemcitabine or S-1 for pancreatic cancer and the effect of sodium rabeprazole (RPZ), a proton-pump inhibitor. GERD was diagnosed in 40% of the patients according to the Frequency Scale for Symptoms of GERD score, and RBZ therapy significantly improved their symptoms.

Assessment of blood-products use as predictor of pulmonary complications and surgical-site infection after hepatectomy for hepatocellular carcinoma

BACKGROUND In perioperative management after hepatectomy, some patients require fresh frozen plasma (FFP) to treat coagulopathy associated with blood loss. However, several studies have suggested a correlation between blood products and pulmonary complications or surgical-site infection (SSI). METHODS The subjects were 99 patients who underwent hepatectomy for hepatocellular carcinoma without plasma exchange for postoperative liver failure in the Department of Surgery, Jikei University Hospital, between January 2000 and December 2006. We investigated the association of 16 factors including age; gender; preoperative ICG(R15); type of resection; concomitant resection of other digestive organs; duration of operation; blood loss; hepatitis virus status; postoperative minimum platelet count, maximum serum total bilirubin (max T-Bil), minimum serum albumin, or minimum prothrombin time; and the dose of red-blood-cell concentration (RC), FFP, platelet concentration, or albumin given in relation to postoperative pulmonary complications and SSI. RESULTS In univariate analysis, pulmonary complications were correlated with gender (P = 0.012), max T-Bil (P = 0.043), dose of RC given (P = 0.007), dose of FFP given (P < 0.001), and dose of albumin given (P < 0.001). In multivariate analysis, pulmonary complications were correlated with FFP given (P = 0.031) and albumin given (P = 0.020), while the incidence of SSI was not correlated with any factors. CONCLUSION Excessive FFP and albumin administration may cause pulmonary complications after hepatectomy.

Comparison of anchoring capacity of mesh fixation devices in ventral hernia surgery.

Background A reliable method of fixation of intraperitoneal mesh is required both in laparoscopic and open surgery for ventral hernia. We evaluated anchoring capacity of 3 fixation devices available for clinical use. Materials and Methods Anchoring capacity of 3 commercially available fixation devices were compared by counting the number of sheets anchored by a single firing under a fixed pressure. A total of 5 trials were conducted for each device. Results The number of sheets fixed (mean±SD) were, 12.4±1.1 for a coil type; 11.4±1.3 for a helical type; and 5.8±0.5 for a staple type tacker. The fixation capacity of the staple type was significantly lower than the other 2 types (P<0.0001). However, there was not statistically significant difference between the coil type and the helical type tackers. Conclusions The helical and coil type tackers in ventral hernia equally provide deep penetration that may contribute to strong fixation of the intraperitoneal mesh to the abdominal wall.

Successful Treatment of Stricture of Duct-to-Duct Biliary Anastomosis After Living-Donor Liver Transplantation of the Left Lobe: A Case Report

Biliary complications, such as stricture or obstruction, after living-donor liver transplantation (LDLT) remain major problems to be solved. Magnetic compression anastomosis (MCA) is a minimally invasive method of biliary anastomosis without surgery in patients with biliary stricture or obstruction. A 66-year-old woman had undergone LDLT for end-stage liver disease for primary biliary cholangitis 20 months previously at another hospital. Computerized tomography showed dilation of the intrahepatic bile duct (B2). Because B2 was invisible with the use of endoscopic retrograde cholangiopancreatography, percutaneous transhepatic biliary drainage (PTBD) was performed for treatment of cholangitis. The rendezvous technique failed because a guidewire could not pass through the biliary stricture. Therefore, we decided to perform MCA. A parent magnet was endoscopically placed distally in the common bile duct of the stricture, and a daughter magnet attached to a guidewire was inserted proximally through the fistula tract of the PTBD. Both magnets were positioned across the stricture, and the 2 magnets were pulled to each other by magnetic power, to sandwich the stricture. By 14 days after MCA, a fistula between B2 and the common bile duct was created. At 28 days after MCA, the magnets were removed distally and a 16-French tube was placed across the fistula. At 7 months after MCA, that tube was removed. In conclusion, when a conventional endoscopic or percutaneous approach including the rendezvous technique fails, MCA is a good technique for biliary stricture after LDLT.