Role of ultrasonically activated scalpel in hepatic resection: a comparison with conventional blunt dissection.

BACKGROUND/AIMS: Our goal was to compare the benefits and complications of using an ultrasonically activated scalpel (UAS) and conventional blunt dissection in hepatic resection. METHODOLOGY: We evaluated the effectiveness of dividing the liver by UAS (n=18) (the UAS group) compared with conventional blunt dissection (n=34) (the BD group) in patients undergoing hepatic resection. In the UAS group, UAS was used to dissect the superficial parenchyma and a crushing and clamping technique was used to divide the deep parenchyma. RESULTS: No serious complications attributable to the use of UAS were encountered, and there were no significant differences in morbidity or mortality between the two groups. The duration of surgery was significantly longer in the UAS group (281 +/- 81 min) than in the BD group (223 +/- 76 min) (P<0.05), and in the UAS group as a whole there were no advantages in using the new scalpel. However, when we compared only those patients who underwent minor hepatectomy, the intraoperative blood loss was significantly less in the UAS group (657 +/- 588mL) than in the BD group (1447 +/- 984mL) (P=0.03). The duration of drainage from the hepatic stump in these patients was also significantly shorter in the UAS group (P=0.02). CONCLUSIONS: The UAS is a useful new device for transection of the liver during hepatic resection. It may reduce the amount of blood loss during liver surgery, particularly in minor hepatectomy.

Role of preoperative transcatheter arterial chemoembolization for resectable hepatocellular carcinoma: relation between postoperative course and the pattern of tumor recurrence.

The effects of preoperative transcatheter arterial chemoembolization (TACE) were retrospectively evaluated in patients with resectable hepatocellular carcinoma (HCC). A total of 227 patients who underwent hepatectomy for HCC were studied (146 underwent preoperative TACE and 81 did not). We compared operative outcome, mortality, and disease-free survival between TACE and non-TACE groups. We also compared the pattern of recurrence and postrecurrence survival between subgroups according to staging. Of the 227 patients, 105 with tumor stage I-II were assigned to group A (group A/TACE, n = 69; group A/non-TACE, n = 36), and the remaining 122 with tumor stage III-IV were assigned to group B (group B/TACE, n =77; group B/non-TACE, n =45). Complete necrosis was found to be more frequent in the TACE group ( p < 0.01). Operating time, blood loss, and mortality did not differ between those who did and did not undergo preoperative TACE. TACE did not significantly improve disease-free survival within either the entire TACE group or group A/TACE. In contrast, in group B/TACE the disease-free survival rates were significantly higher than in group B/non-TACE. Furthermore, both extrahepatic metastasis and diffuse intrahepatic metastasis were significantly more frequent in group B/non-TACE than in group B/TACE. The preoperative TACE also improved the postrecurrence survival in group B. We speculate that preoperative TACE reduced tumor recurrence and that it might confer a survival advantage after surgery, particularly in patients with advanced HCC. In addition, it is expected that this procedure may improve the pattern of tumor recurrence when it does occur.

Immunohistochemical study of the relationship between 8-hydroxy-2'-deoxyguanosine levels in noncancerous region and postoperative recurrence of hepatocellular carcinoma in remnant liver.

Hepatocellular carcinoma (HCC) frequently develops in patients with chronic viral hepatitis and cirrhosis. In these chronic liver disorders, an increased production of reactive oxygen species (ROS) causing oxidative DNA damage has been reported. In this study, we immunohistologically (LSAB method) demonstrated the presence of 8-hydroxy-2'-deoxyguanosine (8-OHdG) that was generated when oxidative DNA damage was caused by active oxygen species in noncancerous region obtained at hepatectomy for HCC, and investigated the relationship between 8-OHdG and remnant liver recurrence. We found that the 8-OHdG labeling index (LI) for noncancerous region at the time of hepatectomy was significantly higher in recurrent (31.1+/-10.2%) than in nonrecurrent (20.6+/-8.0%) patients (P<0.01). The high 8-OHdG LI (>/=30%) group showed a significantly higher recurrence rate, compared with the low LI (<30%) group (P<0.01). The cancer-free survival curves also showed that the high 8-OHdG LI (>/=30%) group had a significantly poorer prognosis because of remnant liver recurrence than the low 8-OHdG LI (<30%) group (P<0.05). The 8-OHdG LI showed a significant correlation with the histopathologic evaluation of noncancerous region based on the New Inuyama Classification: a higher pathologic Staging and a higher pathologic Grading were associated with a higher 8-OhdG LI. Analysis by Grading and Staging showed that the high 8-OHdG LI group (>/=30%) of Grade A2, Stage F3, or Stage F4 had a significantly higher recurrence rate compared with the low 8-OHdG LI group (<30%) of Grade A2, Stage F3, or Stage F4, respectively. In addition, using multivariate analysis, we compared the influence on recurrence of the histological features that, at the time of hepatectomy, showed significant differences in the rate of remnant liver recurrence, that is, the number of tumors and the presence or absence of portal involvement, and three variables of the Grading, Staging, and 8-OHdG LI of noncancerous regions. The results suggested that 8-OHdG LI (P=0.02) and portal involvement (P=0.04), in this order, were useful as independent prognostic factors for recurrence. From this, we consider that, if patients with high 8-OHdG LI (>/=30%) in noncancerous region at the time of hepatectomy are regarded as being at high risk for remnant liver recurrence (heterochronous multicentric carcinogenesis) and are given careful follow-up treatment with preventive therapy for remnant liver recurrence, the prognosis will be improved.

Numerical chromosomal abnormality in gastric MALT lymphoma and diffuse large B-cell lymphoma.

BACKGROUND: We investigated numerical chromosomal abnormalities, using the fluorescence in situ hybridization (FISH) method, in gastric mucosa-associated lymphoid tissue (MALT) lymphoma and diffuse large B-cell lymphoma (DLBL). We also compared the histopathological findings, including the presence or absence of Helicobacter pylori infection, with the analytical results. METHODS: Sixteen patients who underwent operation for malignant gastric lymphoma in our department were divided into three groups: patients with low-grade gastric MALT lymphoma (l-MALT; n = 5), those with high-grade gastric MALT lymphoma (h-MALT; n = 8), and those with DLBL (n = 3). Numerical abnormalities of chromosomes 8, 9, 12, and 17 were investigated by the FISH method, and the presence or absence of H. pylori infection was microscopically examined. RESULTS: Numerical abnormality was observed in chromosome 12 in 11 patients (68.8%), in chromosome 8 in 10 (62.5%), and in chromosome 17 in 5 (31.3%), showing a high frequency. H. pylori infection was detected in 80% and 50% of patients with l-MALT and h-MALT, respectively, but no H. pylori infection was observed in patients with DLBL. CONCLUSIONS: A new biological characteristic of gastric MALT lymphoma was obtained, i.e., a high frequency of numerical abnormalities of chromosomes 12, 8, and 17. There was no correlation between the numerical chromosomal abnormalities and the clinicopathological findings.

Evaluation of a non-shunting operation by measurement of the blood flow velocity using transendoscopic microvascular Doppler sonography for esophageal and gastric varices.

The purpose of this study was to evaluate whether transendoscopic microvascular Doppler sonography (EMDS) is useful to analyze Hassab's operation and esophageal transection (non-shunting operation) which are effective for patients with esophagogastric varices. Twenty patients with esophagogastric varices were examined. Before the operation, we examined the conditions of the esophagogastric varices and measured the velocity of the varices with EMDS. The blood flow velocity in the largest varices (F3) was significantly higher than that in the straight varices (F1). After the operation, the esophageal and gastric variceal blood flow velocities were markedly decreased in 15 patients. In five of the patients who received Hassab's operation, the esophageal variceal form and blood flow velocity still remained. After endoscopic injection sclerotherapy, the velocity and form were completely resolved. The non-shunting operation is effective therapy in the esophageal and gastric varices. It is concluded that EMDS is a non-invasive method and it appears to be very useful for the evaluation of the non-shunting operation.

Hemodynamics in extrahepatic portal vein obstruction and its changes during long-term follow-ups.

Thirty-six patients with extrahepatic portal vein obstruction (EHO) were studied. Twenty-one patients, whose age at onset was under 20 years old, were thought to be primary EHO. Ten of 15 patients over 21 years old, had a history of abdominal diseases, and were thus considered to be secondary EHO; only 5 were primary EHO. EHO was classified into three categories, based on selective celiac-superior mesenteric arteriography, and intraoperative trans-splenic and superior mesenteric venography: the hilar obstruction of portal vein, the portal trunk obstruction, and the portal trunk-splenic vein obstruction. Both primary and secondary EHO cases were found to have extended their obstructed region over time by progressing from hepatic hilum to portal trunk obstruction followed by splenic vein obstruction. On the other hand, based on retrograde portography, EHO was classified into the absence of intrahepatic portal obstruction (portal trunk type) and the intrahepatic obstruction (portal branch type) and the portal branch type tended to predominate. Changes of intra- and extra-hepatic portal obstruction were examined by comparing various angiographies of the 14 patients available for between 1 and 26 years of long-term follow-up. While EHO tended to progress with time, no patient showed progress of a intrahepatic portal vein obstruction. From these results, EHO patients are expected to show continuous progression of EHOs during long-term follow-ups, and to have high recurrence rates of gastrointestinal varices after various treatments due to the persistent portal hypertension. However, effective hepatic flow is likely to be maintained because collateral circulation to the liver develops, and intrahepatic portal vein obstruction does not progress, resulting in a good prognosis for EHO.

Correlation of thymidine phosphorylase staining and the Ki-67 labeling index to clinicopathologic factors and hepatic metastasis in patients with colorectal cancer.

PURPOSE: Our aim was to investigate the thymidine phosphorylase (TdRPase) expression and Ki-67 labeling index (LI) of primary tumors of colorectal cancer and hepatic metastases immunochemically and to evaluate the relationship of these parameters to various clinicopathologic factors and hepatic metastasis. METHODS: We performed immunochemical studies in 74 patients with colorectal cancer, using anti-TdRPase antibody and MIB-1 antibody. RESULTS: TdRPase expression and a Ki-67 LI > or =30% in primary lesions were significantly more common in patients with lymphatic invasion (ly), venous invasion (v), lymph node involvement (n), and hepatic metastasis. A Ki-67 LI > or = 30% of the primary tumor was associated with a significantly higher frequency of metachronous liver metastasis. In the same patients, the mean Ki-67 LI was 24.3+/-17.9 for primary lesions and 5.0+/-4.2 for hepatic metastases, this difference being significant. CONCLUSIONS: These results indicate that TdRPase expression and the Ki-67 LI are related to various clinicopathologic factors, suggesting their usefulness as indices of tumor malignancy. We suggest that the Ki-67 LI of primary colorectal cancer could be an important predictor of the future development of metachronous liver metastasis.