Yaw-Sen Chen

Single and multiple pyogenic liver abscesses: clinical course, etiology, and results of treatment.

Abstract. A total of 483 patients with pyogenic liver abscess during the years 1986 to June 1995 were studied at Chang Gung Memorial Hospital in Kaohsiung: 343 were a single abscess and 140 were multiple abscesses. Males were predominantly affected by this disease. Abdominal pain was more frequent with the single abscess than with multiple abscesses, and jaundice was more frequent with multiple abscesses. Blood levels of alkaline phosphatase, bilirubin, and creatinine and the white blood cell count were significantly higher in patients with multiple abscesses than in those with a single abscess; and the hemoglobin level was higher with single abscesses. The single abscess was usually larger than 5 cm, and the multiple abscesses were usually smaller than 5 cm. The single abscess was always located on the right side (72%) and the multiple abscesses always on the right or both sides. Single abscesses mainly had a cryptogenic origin (58.9%) and multiple abscesses a biliary origin (45.0%). Liver aspirates revealedKlebsiella pneumoniae, Escherichiancoli, Streptococcus, Bacteroides,Enterococcus, among others. K. pneumoniae wasnmore often found in a single abscess and E. coli more oftennin multiple abscesses. Percutaneous catheter drainage and aspirationncomprised the main treatment initially, and the failure rate withnmultiple abscesses was higher than that with single abscesses. Surgicalnintervention should be considered for multiple abscesses because of thenunderlying disease. The overall mortality with multiple abscessesn(22.1%) was higher than that with a single abscess (12.8%). Partialnhepatectomy produced a low mortality rate for both single and multiplenabscesses and should be considered in the presence of severe hepaticndestruction by an abscess or a stone.

The renal‐sparing efficacy of basiliximab in adult living donor liver transplantation

The purpose of this study is to find out whether basiliximab administration will improve postoperative renal function by delaying the start of tacrolimus and decreasing of dosage requirement for tacrolimus in adult living donor liver transplantation (LDLT). Forty‐five adult LDLT recipients were enrolled in the study. The induction group (n = 27) was given basiliximab 20 mg on days 0 and 4; tacrolimus administration was delayed until renal function improved. The control group (n = 18) did not receive basiliximab; tacrolimus was given on the first postoperative day. Trough levels of tacrolimus in the induction and control groups were aimed to be maintained at 5 ‐ 10 ng/ml and 10‐15 ng/ml during the first week after transplant, respectively. The median follow‐up was 22 months (range 10‐34 months). The preoperative conditions were poorer in the induction group (Child C, 56% vs. 33%, P = 0.01; UNOS 2a, 15% vs. 0%, P = 0.02). The intraoperative blood loss was also higher in the induction group than in the control group (median 2,180 ml vs. 495 ml, P < 0.01). The median delay in tacrolimus administration in the induction group was 36 hours (range 24‐108 hours). Serum creatinine levels at second and third postoperative months were significantly lower in the induction group. The creatinine clearance rate in the induction group was higher at the third month posttransplant (median 72 vs. 57 ml/minute, P = 0.04). The incidence of renal insufficiency was significantly lower in the induction group at the third month posttransplant (26% vs. 67%, P < 0.01). Blood cholesterol level at the sixth month posttransplant was lower in the induction group (median 152 vs. 196 mg/dl P = 0.03). The incidences of acute cellular rejection, bacteremia, and cytomegalovirus (CMV) infection were similar in both groups. In conclusion, for pretransplant critical patients with more intraoperative blood loss, basiliximab induction could prevent early renal dysfunction by delaying the start of tacrolimus and reducing the dose requirement of tacrolimus without increasing graft rejection and infection. Furthermore, it also improved renal function as well as lowered cholesterol levels within 6 months after transplantation. (Liver Transpl 2005;11:1258–1264.)

Matrilysin (MMP-7) is a major matrix metalloproteinase upregulated in biliary atresia-associated liver fibrosis

Matrix metalloproteinases (MMPs) are the proteases responsible for tissue remodeling during liver fibrosis caused by various disorders including biliary atresia. However, information regarding the relative contribution of these proteases to liver fibrosis is still limited. We studied matrix metalloproteinase-2 (MMP-2), -7, -9 and -13 mRNA expressions in the liver tissue of early-stage biliary atresia at the time of Kasais procedure, late-stage biliary atresia at the time of liver transplantation with advanced fibrosis and nondiseased control without liver fibrosis. The results of real-time quantitative reverse transcriptase-PCR analysis revealed that only MMP-2 and -7 expressions were significantly different between groups. MMP-2 was significantly higher in Liver Transplantation group than both in Control (P=0.010) and in Kasais Procedure (P=0.001) groups, whereas the difference of MMP-2 expression between Control and Kasais Procedure was not significant. However, the relative expression level of MMP-7 was sequentially elevated when comparing Control, Kasais Procedure and Liver Transplantation groups, and there was significant (P=0.019) difference when comparing Control and Liver Transplantation groups. Moreover, the fold difference in MMP-7 mRNA was much higher than that in MMP-2 mRNA between groups. The expressions of MMP-7 were further confirmed by agarose gel electrophoresis and Western blotting. Immunohistochemical analysis revealed a significant positive correlation of the scores of MMP-7 immunostaining with the stages of liver fibrosis. In situ hybridization demonstrated that the bile ductular epithelial cells, Kupffer cells and hepatocytes were the major producers of matrix metalloproteinase-7 in the liver. Our results imply that MMP-7 is a major MMP associated with the tissue remodeling during the progression of liver fibrosis in biliary atresia.

Needle Tract Implantation of Hepatocellular Carcinoma After Fine Needle Biopsy

The reported incidence of needle tract implantation of hepatocellular carcinoma after fine needle biopsy ranges from 1 to 5%. We collected five cases of hepatocellular carcinoma with needle tract implantation after percutaneous biopsy and tried to determine how this complication affects the clinical outcome. From September 1997 to May 2002, five patients with needle tract implantation of hepatocellular carcinoma were managed in our institution. For treatment of the primary hepatocellular carcinoma, three patients underwent hepatectomy, one had transarterial chemoembolization, and in one patient peritoneal seeding in the needle tract precluded curative resection. All three hepatectomy patients were detected to have tumor implants in the needle tract at an interval of 39 to 58 months after biopsy. These implants were managed with wide surgical excision. Local control was achieved in two patients after repeat resection, whereas the third developed pulmonary metastasis. Thus, in two of five patients, tract implantation after fine needle biopsy changed a potentially curative disease into an untreatable situation. Because of the risk of tumor implantation in the needle tract, we support a policy of selective use of fine needle biopsy for the definitive diagnosis of liver lesions. The patients who do need a biopsy should be carefully followed up for early detection of implanted tumor and its recurrence after resection.

Stress response to hepatectomy in patients with a healthy or a diseased liver.

Partial hepatectomy is a major upper abdominal operation associated with certain stress to the patient. Successful adaptation to such stress is a prerequisite for survival. Donor hepatectomy with maximal safety is a principal concern during living donor liver transplantation. The purpose of the study was to compare the stress response by assessing cytokines and the acute-phase response induced by hepatectomy in patients with a healthy liver and those with a diseased liver. Fourteen patients undergoing partial right hepatectomy were enrolled in this study. Seven of them were donors for living related liver transplantation (group I, or GI); the other seven were patients with hepatocellular carcinoma due to chronic hepatitis B (Child’s class A) (GII). Blood samples for interleukin-6 (IL-6), tumor necrosis factor-α (TNFα), and C-reactive protein (CRP) assays were collected before the operation, at the beginning and end of the operation, and 24 and 48 hours after the operation. The data were analyzed and compared in the same group using the Friedman test and between groups using the Mann-Whitney U-test. A value of p < 0.05 was regarded as significant. Results showed that resection of the liver in patients with both healthy and disease livers leads to significant increases in IL-6 and CPR but not TNFα. Significantly lower levels of IL-6 before and after operation in GI patients compared to those in GII patients suggests that GI patients adapted to surgical stress more easily than did the GII patients.

Isolated ocular motor nerve palsy in dural carotid-cavernous sinus fistula.

The incidence of dural carotid‐cavernous sinus fistula (DCCF) presenting as isolated ocular motor nerve palsies without congestive ocular features is unknown. We reviewed the DCCF patients in our hospital during the last 10u2003years to elucidate the clinical and neuroradiological features of DCCF with isolated ocular motor nerve palsy. Eleven amongst the 33 DCCF patients presented isolated ocular motor nerve palsy. All the 11 patients underwent brain CT/CT angiography (CTA) and/or MRI/MR angiography (MRA), before the digital subtraction angiography (DSA). The compromised nerves were the oculomotor nerve in eight (72.7%), abducens nerve in two (18.2%) and trochlear nerve in one (9.1%). Brain CT and/or CTA were conducted in four patients but all unremarkable. MRI and/or MRA were performed in nine patients and six of them showed compatible findings of DCCF. The diagnoses of DCCFs were confirmed by DSA and all were posterior‐draining type. The outcome was good, with a total recovery rate of 54.5% within 12u2003months. Thirty‐three percent (11 of 33) of our DCCF patients presented with isolated ocular motor nerve palsy, which is not uncommon. MRI and MRA are of value in the initial evaluation, but DSA is necessary for the accurate diagnosis and treatment planning.

Male Breast Cancer: Single Medical Center Experience

Objective: Male breast cancer is uncommon. It shares many similarities with breast cancer in women, but some differences exist. The purpose of this study is: 1) to investigate the experience of male breast cancers at Kaohsiung Chang Gung Memorial Hospital in the past 15 years, and 2) to review the literature with regard to male breast cancer. Methods: We retrospectively analyzed the records of male breast cancer collected from 1992 to 2006 at Kaohsiung Chang Gung Memorial Hospital. All the details of patient demographics, tumor characteristics, including histopathological diagnosis, treatment undertaken and outcomes were collected. Results: The mean age of the 24 male breast cancer patients was 62.4 years, and 10 of the patients had concurrent medical illness. Nineteen patients had a tumor larger than 2 cm. The majority of histopathologic diagnoses was infiltrating ductal carcinoma, and 15 out of the 19 patients (78.9%) had a hormone-receptor-positive disease. All patients underwent modified radical mastectomy, after which 10 patients received post-mastectomy irradiation therapy. Eighteen patients received adjuvant systemic therapy and achieved a 5-year survival rate of 81.3%, better than that for those who did not receive systemic therapy (40%). With a mean follow-up duration of 53.6 months, the breast cancer-specific 5-year survival rate was 71.4% and overall survival was 62.5%. Conclusions: The mean age of men with breast cancer was older than that in the female counterparts and consequently more medical co-morbidities were noted. Men should be made more aware of the disease to achieve an early diagnosis. In addition to surgery and radiation therapy, patients receiving adjuvant systemic therapy had more survival benefit than those who did not.