Toshikazu Suwa

Aggressive surgical approaches to hilar cholangiocarcinoma: Hepatic or local resection?

BACKGROUND It has been reported that surgical excision of hilar cholangiocarcinoma rather than palliative surgical therapy, chemotherapy, or radiotherapy caused prolonged survival in some patients, However, excision is associated with high operative morbidity and mortality rates, particularly when hepatic resection is also performed. The aim of this study was to evaluate the clinical implications of hepatic resection in hilar cholangiocarcinoma. METHODS The study involved 76 patients with hilar cholangiocarcinoma who were undergoing surgical resections. Twenty-one patients (28%) underwent a combined resection, with reconstruction of the portal vein in 20 patients and reconstruction of the hepatic artery in 7 patients. Sixty-five patients undergoing seven different types of hepatic resection with extrahepatic bile duct resection (BDR) and 11 patients undergoing BDR only were retrospectively compared for background, operative morbidity and mortality, and survival. RESULTS Curative resection was obtained in 5 of 11 (45%) patients undergoing local resection and in 49 of 65 (75%) patients undergoing hepatic resection (p < 0.05). The surgical morbidity rates were 34% and 27% for hepatic and local resection, respectively. The 30-day mortality and hospital mortality rates were 4.6% and 15% for hepatic resection and 0% and 0% for local resection, respectively. The 5-year survival rate was 26% for all resected patients (76 patients); it was 40% versus 0% for curative versus noncurative resections (p < 0.05). No significant difference in surgical resection rates was revealed between hepatic and local resection among resected and curative resected patients. CONCLUSIONS Aggressive surgical approaches to obtain curative resections could bring about a better prognosis in hilar cholangiocarcinoma independently of whether hepatic resection or local resection is performed.

Gastrointestinal stromal tumor of the lesser omentum: report of a case.

Abstract We describe herein an extremely unusual case of a gastrointestinal stromal tumor (GIST) of the lesser omentum. A 45-year-old man was admitted to our hospital with an intra-abdominal mass that was subsequently misdiagnosed as a submucosal tumor of the stomach. The tumor arose from the lesser omentum and was removed without difficulty. Histologically, the tumor was composed of spindle–shaped cells with an interlacing bundle pattern, and immunohistochemical examination showed that it was positive for myeloid stem cell antigen (CD34), but negative for HHF35 and S-100 protein. These findings were consistent with a GIST lacking myogenic features and neural attributes. The patient had an uneventful postoperative course, and was free of recurrence when last seen 11 months after his operation.

Radiographic diagnosis and surgical repair of a sciatic hernia: Report of a case

We report the case of a 44-year-old woman who presented with a reducible painless swelling in her left buttock. The mass was preoperatively diagnosed as a sciatic hernia by herniography, which showed the peritoneal sac through the sciatic foramen, and by enterography, intravenous pyelography, and cystography, which demonstrated that the small intestine and urinary bladder had herniated into the sac. The diagnosis and management of this patient are described, followed by a review of the literature on sciatic hernias.

Reduction of hepatic acute phase response after partial hepatectomy in elderly patients

The hepatic capacity for acute phase protein synthesis after partial hepatectomy in the elderly patients was prospectively studied. Forty-one patients who consecutively underwent a partial hepatectomy were grouped according to age of greater or less than 70 years; 12 were in the older group and 29 in the younger. The changes in the levels of serum interleukin-6,α1-antitrypsin,α1-acid glycoprotein, haptoglobin, and plasma fibrinogen were measured after surgery. The postoperative changes in standard liver function tests were also measured. The incidence of postoperative infected complications was 25% in the older group and 7% in the younger (P=0.28). Although postoperative levels of serum interleukin-6 were similar between the two groups, those of serumα1-antitrypsin,α1-antitrypsin glycoprotein, and haptoglobin were significantly lower in the elderly (P<0.05). Postoperative levels of serumα1-antitrypsin and plasma fibrinogen showed an increase of about 30% compared with the preoperative values (P<0.05) in the younger group, but no significant increasein the older. Postoperative deterioration of serum albumin levels and hepaplastin test values was also significantly more severe in the older group (P<0.05). We conclude that in the older patients, a reduction of acute phase protein synthesis occurs after partial hepatectomy as a result of a global deterioration of liver function, and may render patients liable to infection.

Hyperactive Cytokine Response after Partial Hepatectomy in Patients with Biliary Obstruction

The relation of interleukin-6 (IL-6) levels in serum to the postoperative complications was assessed in 50 patients following an extensive hepatectomy. In addition, the postoperative levels of IL-6, tumor necrosis factor-α, and interleukin-1β in peritoneal exudative fluid were determined in 22 patients. The patients with preoperative biliary obstruction showed a higher incidence of postoperative infection compared to those without (44 vs. 12%, p = 0.043). The postoperative serum IL-6 levels on day 1 were significantly higher in patients with postoperative infection than in those without (p < 0.01). Biliary obstruction and intraoperative blood loss contributed to the increase in the serum IL-6 levels in a multiple regression analysis (p = 0.01 and p = 0.044, respectively). Further, the fluid levels of inflammatory cytokines were significantly higher in patients with biliary obstruction than in those without (p < 0.05). These results suggest that in patients with biliary obstructions a hyperactive cytokine response occurs after an extensive hepatectomy and results in a high incidence of postoperative infection.

Increased Serum Interleukin-6 Level and Reduction of Hepatic Acute-Phase Response after Major Hepatectomy

It has been proposed that a major hepatectomy impairs the liver-related host defense mechanism. The changes in the levels of serum inflammatory cytokines and plasma acute-phase proteins synthesized in the liver were measured after partial hepatectomy. Peak levels of serum interleukin-6 were significantly higher after extended lobectomy than after lobectomy or segmentectomy (p < 0.01). Serum interleukin-1 beta and tumor necrosis factor alpha levels showed no significant changes. Plasma levels of acute-phase proteins were significantly lower after lobectomy or extended lobectomy (p < 0.05). A reduced hepatic acute-phase response probably renders patients liable to infection after major hepatectomy.

Anti‐inflammatory response in patients with obstructive jaundice caused by biliary malignancy

Background: Obstructive jaundice potentially modulates the host defense mechanism resulting in perioperative infection. It has been reported that a systemic inflammatory response occurs in patients with obstructive jaundice. An anti‐inflammatory response was studied in 29 jaundiced patients undergoing biliary drainage.

Plasma human hepatocyte growth factor concentrations in patients with biliary obstruction

Background : It has been suggested that human hepatocyte growth factor (hHGF) maintains the growth and viability of hepatocytes and biliary epithelial cells. The purpose of this study was to determine plasma hHGF concentrations in patients with obstructive jaundice and to correlate these findings with clinical outcome.

A new sterilization technique with balloon-tube thoracostomy for thoracic empyema

OBJECTIVE Failure or prolongation of treatment for refractory thoracic empyema by the current chest-tube drainage technique is often due to sterilization difficulties. Insufficient sterilization prolongs hospitalization, and is often associated with life-threatening complications and/or additional invasive surgical procedures. A new chest-tube sterilization technique aimed at making it less invasive and shortening the therapy is proposed. METHODS Following pretreatment for complications including loculation, bronchopleural fistula, or corticated lung, a double-lumen trocar catheter was introduced at the bottom of the empyemic cavity through the lateral chest wall. Then, a Foley balloon urethra-catheter was inserted and attached just inside the anterior chest wall at the top of the cavity for the evacuation of intrathoracic air. After irrigation of the cavity with distilled water once or twice, the cavity was completely filled with a bactericidal solution which was left in place for 30-60 minutes, followed by an antibiotic solution for more than 20 hours. RESULTS Among the five treated post-lobectomy or pneumonectomy cases, sterilization was obtained after only one treatment in four cases and after two courses in the other. Catheterization duration from the initial treatment was 2-13 days. Neither recurrence nor treatment-related major complications were observed. CONCLUSIONS This balloon-tube thoracostomy technique is simple, minimally invasive and cost-effective, due to shortening of the treatment time with minimal manpower and equipment requirements. It is thus a promising therapeutic approach to thoracic empyema and has the potential for application to other intrathoracic disorders.

Long-Term Survival Achieved by Resection of Metastases in the Liver and Lung in a Patient with Recurrent Colonic Cancer: Report of a Case

Abstract A 58-year-old man who underwent a potentially curative resection of cancer of the sigmoid colon at another hospital was subsequently followed up at our hospital. A lateral segmentectomy was per-formed for a solitary hepatic metastasis, and partial resection of right S1 was later carried out for a pulmonary metastasis. Another pulmonary metastasis was found 6 years after his third operation and to minimize the area to be resected, bronchial arterial infusion chemotherapy was performed twice. A 51% reduction in the size of the tumor was achieved, so a right upper lobectomy and wedge resection of the bronchus were performed. The patient remains alive 14 years after the initial resection of colonic cancer. This case is considered noteworthy because it demonstrates the potential effectiveness of local adjuvant chemotherapy and the possibility of extended survival in a patient who has undergone resection of both hepatic and pulmonary metastases from colonic cancer.