Teruo Komokata

Acceleration of primary liver tumor growth rate in embolized hepatic lobe after portal vein embolization.

Background: Portal vein embolization (PVE) is now widely accepted as a useful preoperative procedure in selected patients undergoing extended hepatectomy. However, the effect of PVE on the growth of liver tumors has not been fully elucidated. Purpose: To retrospectively evaluate the effects of PVE on the growth of liver tumors in the embolized lobes. Material and Methods: Eight patients with a primary liver tumor, six hepatocellular carcinomas (HCC) and two cholangiocellular carcinomas (CCC), were studied. The growth rates of the tumors in the embolized lobes and non-embolized liver parenchyma were calculated using the computed tomography (CT) volume values at the time of tumor identification, and before and after PVE. Result: The median tumor growth rate was 0.59 cm3/day (range 0.22–6.01 cm3/day) before PVE and 2.37 cm3/day (range 0.29–13.97 cm3/day) after PVE (P = 0.018). The tumor growth acceleration ratios ranged from 1.50 to 7.46 (median 2.65) in the six HCCs, and were 1.00 and 1.32 in the two CCCs. There was no apparent correlation between the tumor growth rate after PVE and the growth rate of non-embolized liver parenchyma (median 6.00 cm3/day, range 1.24–11.0 cm3/day). Conclusion: Liver tumor growth in an embolized lobe accelerates after PVE, in patients with HCC.

Retractile mesenteritis of the large bowel: Report of a case and review of the literature

We report herein the case of a 46-year-old woman found to have retractile mesenteritis of the rectosigmoid colon. A review of 52 cases of retractile mesenteritis of the large bowel collected from the literature is discussed following our case report. The average age of the patients was 54.5 years and the male:female ratio was 37:15. The majority of lesions (61.5%) were located in the rectosigmoid colon, with abdominal pain, an abdominal mass, constipation, and fever being the most common symptoms. The diagnosis was only able to be made at the time of laparotomy in 90.4% of the patients. The gross appearance at surgery was characterized by a thickened, shortened, and retractile mesentery, forming nodular masses involving the appendices epiploicae of the colon. Microscopically, fibrosis, inflammatory cell infiltrations, degeneration of the fatty tissue or fat necrosis, and aggregations of lipid-laden foamy cells were observed in most patients. The mass involving the colon was resected in 59.6% of the patients, but even external or bypass colostomy demonstrated favorable results.

The impact of donor chemical overdose on the outcome of liver transplantation.

Background. To overcome the critical shortage of liver grafts, many centers have been widening the acceptance criteria for liver donation. Use of liver grafts from victims who have suffered chemical overdose (COD) may be one option that could help to expand the donor pool. However, this practice has been poorly documented. Methods. Of 1,195 orthotopic liver transplantations performed at our institution between June 1994 and March 2001, 22 involved livers (1.8%) were retrieved from COD donors. Donor and recipient characteristics and posttransplantation outcomes were analyzed retrospectively. Results. The main chemicals causing brain death of the donor were carbon monoxide (n=4), cocaine (n=4), tricyclic antidepressants (n=3), 3,4-methylenedioxy- methamphetamine (n=2), opiates (n=2), aspirin (n=1), gamma hydroxybutyrate (n=1), heroin (n=1), insulin (n=1), verapamil (n=1), barbiturate (n=1), and brompheniramine/phenylpropanolamine (n=1). Primary nonfunction developed in one patient who had received a liver from an 3,4-methylenedioxymethamphetamine-intoxicated donor. Another patient died of fungal meningitis 10 days after transplantation with a functioning graft. The remaining 20 patients experienced acceptable early graft function, as demonstrated by initial mean peak values of bilirubin (4.8 mg/dL), aspartate aminotransferase (624 U/L), and alanine aminotransferase (730 U/L). One-year graft survival rate estimated by the Kaplan-Meier method was 86%. Conclusions. Satisfactory outcomes of graft function were achieved in orthotopic liver transplantations from COD donors. The cautious use of liver grafts from selected COD donors may be a worthwhile method of increasing the availability of scarce donor organs.

A Switch in the Dynamics of Intra-Platelet VEGF-A from Cancer to the Later Phase of Liver Regeneration after Partial Hepatectomy in Humans

Background Liver regeneration (LR) involves an early inductive phase characterized by the proliferation of hepatocytes, and a delayed angiogenic phase distinguished by the expansion of non-parenchymal compartment. The interest in understanding the mechanism of LR has lately shifted from the proliferation and growth of parenchymal cells to vascular remodeling during LR. Angiogenesis accompanied by LR exerts a pivotal role to accomplish the process. Vascular endothelial growth factor (VEGF) has been elucidated as the most dynamic regulator of angiogenesis. From this perspective, platelet derived/Intra-platelet (IP) VEGF-A should be associated with LR. Material and Methods Thirty-seven patients diagnosed with hepatocellular carcinoma and undergoing partial hepatectomy (PH) were enrolled in the study. Serum and IP VEGF-A was monitored preoperatively and at four weeks of PH. Liver volumetry was determined on computer models derived from computed tomography (CT) scan. Results Serum and IP VEGF-A was significantly elevated at four weeks of PH. Preoperative IP VEGF-A was higher in patients with advanced cancer and vascular invasion. Postoperative IP VEGF-A was higher after major liver resection. There was a statistically significant correlation between postoperative IP VEGF-A and the future remnant liver volume. Moreover, the soluble vascular endothelial growth factor receptor-1 (sVEGFR1) was distinctly down-regulated suggesting a fine-tuned angiogenesis at the later phase of LR. Conclusion IP VEGF-A is overexpressed during later phase of LR suggesting its implications in inducing angiogenesis during LR.

Post-Resection Exhaustion of Intra-Platelet Serotonin: Also an Indicator of Early Hepatocellular Carcinoma Recurrence?

Purpose: Serotonin (5-hydroxytryptamine, 5-HT) is well known for its growth stimulatory effect on several types of carcinoma and tumor cells. Since a large portion of 5-HT is stored and transported by platelets, the aim of this study was to assess the influence of platelet-sequestered 5-HT on post-resection hepatocellular carcinoma (HCC) recurrence. Methods: This pilot study was conducted in a cohort of forty patients diagnosed with HCC undergoing partial hepatectomy. 5-HT levels in serum, plasma and intra-platelet (IP) were monitored preoperatively and four weeks after liver resection. The patients were followed every three months after the surgery. Results: Follow-up was standardized to a fixed length of time. Fifteen patients (37.5%) developed HCC recurrence during 18 months follow-up. Patients with recurrence had significantly reduced serum and IP 5-HT levels at four weeks of liver resection (P = 0.003 and P = 0.014 respectively). Accordingly, in the Cox regression hazard model, serum and IP 5-HT were able to independently predict the recurrence (hazard ratio = 0.1, 95% confidence interval = 0.01 - 0.75 and hazard ratio = 0.1, 95% confidence interval = 0.01 - 0.89 respectively). The optimal cut-off value of 42.77 ng/ml for serum [area under the curve (AUC): 0.78, P = 0.003] and 0.3117 ng per 106 platelets (AUC: 0.733, P = 0.015), on receiver operating characteristic (ROC) curve corresponded to maximum sensitivity and specificity of prediction. The disease free interval was significantly worse in patients with low serum and IP 5-HT (P = 0.001 and P = 0.029 respectively). Conclusion: IP 5-HT monitored during early follow-up, after liver resection may represent a useful marker of early HCC recurrence.

Allograft rejection of small bowel transplantation in pigs.

n = 9): nonimmunosuppressed recipients; (2) group 2 (n = 8): FK506-immunosuppressed recipients; (3) group 3 (n = 2): autotransplant controls; and (4) donors (n = 17). Orthotopic small bowel transplantations were performed with Thiry-Vella loops for daily biopsies. The survival rate of group 2 was significantly longer than that of group 1 (P < 0.05). One best survivor in group 2 was killed at postoperative day (POD) 365. Treatment by FK506 prevented rejection, but most of the pigs died of pneumonia. In group 1, rejection began on POD 3 and progressed to severe rejection rapidly within 7 days. In group 2, rejection began from POD 6 to POD 8, but either remained mild or spontaneously improved. The differences in the routine laboratory data and the tumor necrosis factor-α level were not evident between the groups. Histological studies of repeated graft biopsies are thus considered to be essential for detecting signs of graft rejection.

Portal vein obstruction accompanied by intrahepatic stones

This study was conducted to clarify the pathogenesis of portal vein obstruction (PVO) associated with intrahepatic stones. Five cases with PVO and intrahepatic stones were studied retrospectively. The coincidence rate of PVO in intrahepatic stones was 5.8% (5 of 86 cases), and that of intrahepatic stones in PVO, 45.5% (5 of 11 cases). All cases had one or more symptoms of cholangitis, such as high-grade fever, abdominal pain, and jaundice prior to diagnosis of PVO. The portal vein was occluded at the main trunk in 4 and in the left branch in 1. Intrahepatic stones were found in bilateral hepatic lobes in 3 and in the left lobe in 2. Numerous calcium bilirubinate stones were packed in dilatated intrahepatic bile ducts of an excised specimen of the liver. Microscopically, arterial structures could be seen, but the portal vein ceased to be evident about the involved bile duct. Based on the results of this study, persistent cholangitis and packed gallstones were concluded essential to the development of PVO accompanied by intrahepatic stones.

Simultaneous operation for cardiac disease and gastrointestinal malignancy

AIM To investigate the safety of performing simultaneous cardiac surgery and a resection of a gastrointestinal malignancy. METHODS Among 3664 elective cardiac operations performed in adults at Kagoshima University Hospital from January 1991 to October 2009, this study reviewed the clinical records of the patients who underwent concomitant cardiac surgery and a gastrointestinal resection. Such simultaneous surgeries were performed in 15 patients between January 1991 and October 2009. The cardiac diseases included 8 cases of coronary artery disease and 7 cases with valvular heart disease. Gastrointestinal malignancies included 11 gastric and 4 colon cancers. Immediate postoperative and long-term outcomes were evaluated. RESULTS Postoperative complications occurred in 5 patients (33.3%), including strokes (n = 1), respiratory failure requiring re-intubation (n = 1), hemorrhage (n = 2), hyperbilirubinemia (n = 1) and aspiration pneumonia (n = 1). There was 1 hospital death caused by the development of adult respiratory distress syndrome after postoperative surgical bleeding followed aortic valve replacement plus gastrectomy. There was no cardiovascular event in the patients during the follow-up period. The cumulative survival rate for all patients was 69.2% at 5 years. CONCLUSION Simultaneous procedures are acceptable for the patients who require surgery for both cardiac diseases and gastrointestinal malignancy. In particular, the combination of a standard cardiac operation, such as coronary artery bypass grafting or an isolated valve replacement and simple gastrointestinal resection, such as gastrectomy or colectomy can therefore be safely performed.

Middle-preserving pancreatectomy with reversed pancreaticogastrostomy: report of a case

Parenchyma-sparing pancreatic resections have been reported increasingly in recent years; however, for multifocal diseases involving the head and the tail of the pancreas, total pancreatectomy is still the preferred procedure. The possible consequence of this procedure is loss of normal pancreatic parenchyma, resulting in insufficiency of pancreatic exocrine and endocrine functions. Various types of limited resection have been introduced for isolated or multiple pancreatic lesions, depending on the location of the tumor. Even for multifocal diseases, if the pancreatic body is spared, a middle-preserving pancreatectomy (MPP) can be performed to assure maximal pancreatic function and uncompromised quality of life. Yet, few papers have introduced the feasibility of MPP for a better outcome. This report describes a new surgical technique for MPP using an alternative approach for the remnant pancreas anastomosis. We used this technique successfully to remove a bifocal neoplasm: adenocarcinoma of the distal bile duct and mucinous cyst adenoma in the tail of the pancreas.

Deciphering Platelet Kinetics in Diagnostic and Prognostic Evaluation of Hepatocellular Carcinoma

Liver pathophysiology can, directly and indirectly, impose morphological or biochemical abnormalities of the platelets. Conversely, platelets are also able to regulate the promitogenic and profibrotic signals on liver pathobiology. Platelet contribution to the liver pathophysiology is typically facilitated by the platelet-derived growth factors that are sequestered in different subsets of alpha and dense granules, and the release of these growth factors is synchronized according to the stage and type of liver disease or injury. Thus, platelets harbor clinically relevant information with potential diagnostic and prognostic implications in liver diseases. Hepatocellular carcinoma (HCC) largely influences the platelet kinetics, and a growing body of evidence has recognized its association with HCC occurrence or prognosis. This narrative review summarizes the progress made on implicating platelet as a diagnostic and prognostic tool for HCC; the review also dissects the contradictory results from earlier studies and reflects how combining platelet-based information may enable more reliable test for diagnostic and prognostic evaluation of HCC.