Liver functional analysis by total bile acid level of C-tube bile after hepatectomy.

BACKGROUND/AIMS: In order to predict liver failure which can lead to death after hepatectomy, a sensitive and specific indicator is needed for liver function. Transcystic duct tube (C-tube) drainage after hepatectomy is thought to be useful in decreasing postoperative complications. METHODOLOGY: Conventional serum liver function tests, and total bile acid (TBA) and total bilirubin (T.Bil) concentration levels of bile from a C-tube in 11 hepatectomized patients who underwent C-tube drainage were compared on postoperative day 2 (Day 2) and postoperative day 7 (Day 7). RESULTS: When serum liver function tests were improving between Day 2 and Day 7, the TBA concentration in bile was increasing in contrast to a decreasing T.Bil concentration. On Day 7, TBA concentrations in the bile in patients without liver cirrhosis or with low ICGR15 values were higher than those in patients with liver cirrhosis or with high ICGR15 values, whereas there were no significant differences between T.Bil bile concentrations in the two groups on Day 7, that is, the measurement of TBA bile concentration might be a faster and more accurate parameter for liver function than that of T.Bil bile concentration. CONCLUSIONS: TBA bile concentration obtained from C-tubes was a useful liver function indicator after hepatectomy.

Increased expression of thymidine phosphorylase in tumor tissue in proportion to TP-expression in primary normal tissue.

Thymidine phosphorylase (TP) is considered to be a key enzyme affecting the prognosis of patients with advanced gastrointestinal cancer. We tried to demonstrate the correlation of TP expression in tumor tissue and adjacent normal tissue, that is, primary normal tissue. The present study was designed to quantify TP level by enzyme-linked immunosorbent assay (ELISA) in tumor tissue and adjacent normal tissue obtained from 42 hepato-gastrointestinal cancer patients including 15 with gastric, 19 with colorectal and 8 with hepatocellular carcinomas. TP levels in tumor tissues were higher than those in adjacent normal tissues (p<0.001). There was a significant correlation between the expression of TP in tumor tissue and adjacent normal tissue (R=0.711, p<0.001; y=23.420+1.534x). On the other hand, there was no significant correlation between the ratio of tumor to adjacent normal tissue levels of TP (TP T/N) and expression of TP in tumor tissue (R=0.250, p=0.110). Thus, TP expression in tumor tissue may be high in proportion to TP expression in primary tissue. Furthermore, in clinical care, not only TP level in tumor tissue but also TP T/N value should be considered when using anticancer agents that become effective after conversion by TP to the active drug 5-FU.

Chemotherapy and serum hyaluronic acid levels in malignant peritoneal mesothelioma.

We report a case of malignant peritoneal mesothelioma in a 63-year-old man. Right hemicolectomy, partial ileectomy, partial omentectomy, excision of the abdominal wall, and catheterization for intraperitoneal infusion chemotherapy were performed as surgery. Histopathologically, the tumor was composed of papillary and sheet-like proliferation of atypical cells for which an Alcian Blue digestive test with hyaluronidase was positive. By immunohistochemical staining, the tumor cells were stained against HBME-1 and thrombomodulin antibodies. The final diagnosis was a diffuse malignant mesothelioma of the epithelial type. Sequential adjuvant chemotherapies of cisplatin (ip) plus 5-fluorouracil (iv), cisplatin (iv) plus 5-fluorouracil (iv), and mitomycin C (iv) were administered. He is still alive 46 months after surgery. Moreover, the increase in serum hyaluronic acid levels has been related to tumor volume, and has been useful for clinical follow-up. Secondly, we reviewed major chemotherapy previously described for malignant mesothelioma. The total response rate was 469 of 2,493 cases (18.8%). The response rates with single agent chemotherapy, combination chemotherapy, intraperitoneal or intracavitary chemotherapy, continuous hyperthermic peritoneal perfusion chemotherapy, and immunochemotherapy were 150 of 1,146 cases (13.1%), 209 of 1,019 cases (20.5%), 63 of 133 cases (47.4%), 11 of 13 cases (84.6%), and 36 of 182 cases (19.8%), respectively. Direct exposure of antitumor agent to the peritoneal surface is considered to be most effective against malignant peritoneal mesothelioma.

Surgical treatment for an extrahepatic portosystemic shunt: a case report.

An extrahepatic portosystemic shunt that has neither liver cirrhosis nor portal hypertension is rare. A 60-year-old Japanese woman who had been suffering chronic liver disease and anemia with mild disorientation was admitted to investigate general fatigue with dizziness and disorientation. The laboratory data revealed mild pancytopenia and liver dysfunction including hyperammoniemia, an increased Indocyanine Green 15-min retention rate, and a decreased Fischer's ratio. Color Doppler ultrasonography, computed tomography, and arterial portography revealed an extrahepatic portosystemic shunt that extended tortuously from the superior mesenteric vein into the inferior vena cava, and decreased blood flow in the main portal vein. Judging from intraoperative measurement of portal pressure and intraoperative portography, shunt ligations were performed at both the efferent portion of shunt from the superior mesenteric vein and the afferent portion of the shunt into the inferior vena cava, and resection of the spleen was also performed. On the postoperative laboratory data, pancytopenia disappeared, and liver function improved. Postoperative abdominal imaging showed increased blood flow in the main portal vein and disappearance of the shunt vessel. Moreover, symptoms present before surgery also disappeared. In conclusion, surgical treatment of extrahepatic portosystemic shunts may result in better postoperative quality of life if it is performed in carefully selected patients.

Thymidine phosphorylase and dihydropyrimidine dehydrogenase expression in hepatocellular carcinoma and metastatic liver cancer.

Thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) are considered to be key enzymes affecting the prognosis for patients with various cancers. We tried to prove the correlation of TP and DPD expression in hepatocellular carcinoma (HCC) and liver metastasis. We quantified TP and DPD levels by an enzyme-linked immunosorbent assay (ELISA) in the tumor (T) and adjacent normal tissue (N) obtained from 8 HCC patients, and 11 liver metastasis patients together with 9 of their primary cancers. TP levels were higher in the primary cancer, liver metastasis, and HCC compared with each adjacent tissue. TP levels were higher in HCC than in liver metastasis, and TP levels in the adjacent tissues of HCC were also higher than those in adjacent tissues of liver metastasis. TP levels were higher in liver metastasis than in primary cancer, and TP levels in adjacent tissues of liver metastasis were also higher than those in adjacent tissues of primary cancer. However, there were no differences in TP T/N ratio between HCC and liver metastasis, and between primary cancer and liver metastasis. DPD levels were lower in the liver metastasis compared with the adjacent liver tissues, and DPD levels in liver metastasis or its adjacent liver tissues were higher than those in primary cancer or its adjacent tissues. There were no differences in DPD T/N ratio between HCC and liver metastasis, and between primary cancer and liver metastasis. Thus, we demonstrated that TP was highly expressed in liver malignancy. We may be able to increase the success of anticancer chemotherapy for liver malignancy while decreasing the side effects by analysis of T/N ratios in TP, DPD, and TP/DPD in addition to TP expression.

Preoperative endoscopic analysis of thymidine phosphorylase and dihydropyrimidine dehydrogenase in gastrointestinal cancer.

Thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) are considered to be key enzymes affecting the prognosis for patients with advanced gastrointestinal cancer. Preoperative examination of TP and DPD expression levels and assessment of these enzymes in inoperable cancer patients may contribute to successful treatment. We tried to prove the correlation of TP and DPD expression in preoperative specimens by endoscopy and in surgical specimens. The present study was designed to quantify TP and DPD levels by enzyme-linked immunosorbent assay (ELISA) in tumor tissue obtained from 30 gastrointestinal cancer patients by preoperative endoscopy and surgery, including 15 gastric and 15 colorectal cancers. Successful cases as those in which cancer cells were demonstrated histologically in preoperative specimens by endoscopy were 12 (success rate: 80%) in gastric cancer patients, and 15 (success rate: 100%) in colorectal cancer patients. In successful cases, there were almost significant correlations in all cases, gastric cancer, and colorectal cancer among the expression of TP, DPD, and TP/DPD ratio in each preoperative specimen by endoscopy and surgical specimen, respectively. On the other hand, in the gastric cancer group, 3 unsuccessful cases resulted in a significant departure from ideal equation compared with 12 successful cases. In actual clinical care, physicians should pay attention to and evaluate carefully the data from endoscopical biopsy specimens in which cancer cells may not be demonstrated histologically. Thus, endoscopic analysis of TP and DPD expression in preoperative or inoperable cancer patients may contribute to successful treatment.

Comparative analysis of thymidine phosphorylase and dihydropyrimidine dehydrogenase expression in gastric and colorectal cancers.

Thymidine phosphorylase (TP) and dihydropyrimidine dehydrogenase (DPD) are considered to be key enzymes affecting the prognosis for patients with gastric and colorectal cancers. We tried to prove the correlation of TP and DPD expressions in gastric and colorectal cancers. The present study was designed to quantify TP and DPD levels by an enzyme-linked immunosorbent assay (ELISA) in tumors and normal tissues obtained from 16 gastric and 20 colorectal cancer patients. TP and TP/DPD ratio in the tumor specimens were almost all higher than those in each normal tissue, especially for tumors in the progressive state. In the early stage of the colorectal cancer group, DPD in the normal tissues were higher than those in the tumor specimens. There were no significant differences between TP levels in the tumor specimens of the two groups, whereas in stages III and IV, those of the gastric cancer group tended to be higher than those of colorectal cancer group. In stages I and II, DPD levels in the tumor specimens tended to be higher in the gastric cancer group than in the colorectal cancer group. DPD T/N was higher in the gastric cancer group than in the colorectal cancer group. There were no significant differences between TP/DPD ratios in the tumor specimens of the two groups, whereas those in normal tissue were higher in the gastric cancer group than in the colorectal cancer group. We may be able to achieve the successful effects or reduction of side effects of anticancer chemotherapy for gastric and colorectal cancer using the results of this study.

A traumatic neuroma of the bile duct: a case report.

Traumatic neuroma of the bile duct is not a true neoplasm, but a reactive proliferation of pericholangial nerve tissue induced by injury. A 60-year-old Japanese man was admitted to investigate obstructive jaundice. He had undergone cholecystectomy and common bile duct exploration 17 years previously. Ultrasonography and computed tomography showed a pneumobilia with dilatation of the intrahepatic biliary ducts. Endoscopic retrograde cholangiography and spiral-computed tomography cholangiography revealed biliary stenosis in the hepatic hilus with dilatation of the intrahepatic biliary ducts. Celiac angiography and arterial portography showed neither tumor stains nor signs of vessel invasion. At surgery, the confluent portion of the intrahepatic biliary ducts in the hepatic hilus was hardly palpable and deformed, but frozen-section microscopic examination confirmed that no malignant cells were present. Anastomosis of the right and left extrahepatic bile duct to the jejunum, reconstructed by Roux-en-Y hepaticojejunostomy, was performed. Histological examination revealed a nodule composed of a haphazard proliferation of nerve fascicles in the fibromuscular layer of the bile duct which were positively stained for S-100 protein. The pathological diagnosis was traumatic neuroma of the bile duct. Thus, the possibility of traumatic neuroma should be considered in the differential diagnosis of patients with late-onset jaundice after biliary tract surgery.

Evaluation of postoperative nutritional state after hepatectomy for hepatocellular carcinoma.

BACKGROUND/AIMS: In spite of many technical advances in liver surgery, optimal nutritional support after hepatectomy has not been established. METHODOLOGY: We clarified the actual nutritional state in 16 patients with total parenteral nutrition (TPN group), and 16 patients without total parenteral nutrition (PPN group), after hepatectomy for hepatocellular carcinoma without biliary tract reconstruction, in terms of preoperative clinical data, intraoperative indexes, postoperative management and complications, liver function data, nutritional state, and changes in metabolic parameters. RESULTS: There were no significant differences in any occurrences of postoperative complications, liver function data, or nutritional parameters between the two groups. On the other hand, the TPN group needed more doses of insulin than the PPN group. The beginning of each water and food intake was earlier in the PPN group than in the TPN group. The blood glucose level was higher in the TPN group than in the PPN group. The serum sodium and chloride levels were lower, but the serum potassium level was higher, in the TPN group compared to the PPN group. Thus, problems such as hyperglycemia and serum electrolyte abnormalities were more conspicuous in the TPN group than in the PPN group. CONCLUSIONS: In the actual clinical care after hepatectomy for hepatocellular carcinoma without biliary tract reconstruction, in which oral feeding is started early, total parenteral nutrition is considered unnecessary.

Hyperamylasemia after hepatectomy in chronic liver disease patients.

BACKGROUND/AIMS: Postoperative hyperamylasemia after hepatectomy occurs frequently, but the mechanism is not clear. METHODOLOGY: We studied the postoperative evaluation of 11 patients with hyperamylasemia after hepatectomy (Hyper-Amy group), compared with 35 patients without hyperamylasemia (Norm-Amy group), in terms of preoperative features, intraoperative findings or procedures, postoperative management and complications, parameters for pancreatitis, and comparisons in serum amylase and lipase levels between patients with chronic liver disease and those with normal livers. RESULTS: In preoperative features, viral infection and chronic liver disease presented much more in the Hyper-Amy group than in the Norm-Amy group, and indocyanine green 15-minute retention rate was higher in the Hyper-Amy group than in the Norm-Amy group. There were no significant differences in the intraoperative findings or procedures, or postoperative management and complications between the two groups. In parameters for pancreatitis, the serum amylase and lipase levels were higher in the Hyper-Amy group than in the Norm-Amy group on days 3, 7 and 14. In comparison, between patients with chronic liver disease and normal livers, the serum amylase levels were higher in patients with chronic liver disease than in patients with normal livers on days 7 and 14. CONCLUSIONS: We should pay attention to the incidence of hyperamylasemia after hepatectomy in patients with chronic liver disease, so we can give rapid treatment for pancreatitis.

Biliary drainage tube evaluation after common bile duct exploration for choledocholithiasis.

BACKGROUND/AIMS: We studied the postoperative evaluation of transcystic duct tube drainage (C-tube), T-tube drainage (T-tube), and retrograde transhepatic biliary drainage after common bile duct exploration for patients with choledocholithiasis. METHODOLOGY: We analyzed the preoperative clinical features of patients, intraoperative findings, postoperative status and management, daily output of bile, liver function, postoperative infections, and postoperative complications for patients who underwent common bile duct exploration including 16 C-tube, 17 T-tube, and 8 retrograde transhepatic biliary drainage cases. RESULTS: There were no significant differences in the preoperative clinical features, intraoperative findings, or the daily output of bile from the tube. The removal day of the biliary drainage tube and postoperative hospital stay were shorter in the C-tube group than in the T-tube and retrograde transhepatic biliary drainage groups. Aspartate amino-transferase level and body temperature in the C-tube group on day 7 were lower than those in the T-tube group, and the total bilirubin level in the C-tube group on day 14 was lower than in the T-tube and retrograde transhepatic biliary drainage groups. Moreover, postoperative complications occurred significantly less frequently in the C-tube group (25.0%) than in the T-tube group (76.5%). CONCLUSIONS: C-tube drainage is thought to be most useful after common bile duct exploration for patients with choledocholithiasis.

Postoperative evaluation of C-tube drainage after hepatectomy.

BACKGROUND/AIMS: In spite of recent advances in liver surgery, biliary complications remain a common cause of major morbidity after hepatectomy. METHODOLOGY: We studied the postoperative evaluation of 28 hepatectomied patients with transcystic duct tube (C-tube) drainage (C-group), compared with 38 hepatectomied patients without C-tubes (NC-group), in terms of preoperative clinical profiles of patients, intraoperative findings and procedures, postoperative management and bile leakage, daily output of bile, liver function and postoperative infections. RESULTS: There were no significant differences in the preoperative clinical profiles of patients and postoperative management between the two groups. In intraoperative findings and procedures, the tumor size, weight of the resected liver, operation time and operative blood loss were higher in the C-group than those in the NC-group. Therefore, the operative procedure was more serious in the C-group than that in the NC-group. However, bile leakage was observed in only one of 28 patients (3.6%) in the C-group and 10 of 38 patients (26.3%) in the NC-group, that is, bile leakage occurred less frequently in the C-group than in the NC-group. The daily output of bile in the C-group was thought to be enough to decompress the biliary tree. In liver function, aspartate aminotransferase and alanine aminotransferase had lower levels in the C-group than those in the NC-group with bile leakage. White blood cell count, C-reactive protein and body temperature were closer to the normal range in the C-group than those in the NC-group with bile leakage. CONCLUSIONS: C-tube drainage after hepatectomy is thought to be useful for decreasing postoperative complications, especially bile leakage.

Study of the absorption of cefcapene pivoxil in patients with infectious disease and soft stool or diarrhea.

Cefcapene pivoxil hydrochloride (CFPN-PI), an ester cephem antibiotic, was orally given at a dose of 100 mg three times daily in patients with infection and soft stool or diarrhea, and its absorption was determined using the recovery ratio of 12-h urine pooled after the initial administration as an index. The primary endpoint, the recovery ratio of 12-h urine pooled after oral administration, could be evaluated in six of the eight patients finally gathered, and the mean value was 30.1 +/- 5.8%, which was not considered to differ from the mean value of 34.4 +/- 5.5% obtained in six healthy adult volunteers in the previous phase I study. Clinical efficacy in the eight patients was rated as very effective, effective, and ineffective in two, five, and one patients, respectively, with an effective ratio of 87.5% (7/8). Neither adverse drug reactions nor abnormal laboratory data were observed in any patient. These results indicate that CFPN-PI, at the routine oral dose, does not cause any problems in terms of absorption, efficacy, and safety when it is used in patients with infection and soft stool or diarrhea.