Preoperative estimation of remnant hepatic function using fusion images obtained by (99m)Tc-labelled galactosyl-human serum albumin liver scintigraphy and computed tomography.

BACKGROUND: Assessment of hepatic functional reserve is important in hepatic resection. The aim of this study was to evaluate the role of hepatic asialoglycoprotein receptor (ASGP-R) analysis in the preoperative estimation of remnant liver function in liver surgery. METHODS: One hundred and one patients undergoing hepatic resection for liver tumours were studied. Seventeen patients had preoperative percutaneous transhepatic portal vein embolization (PTPE). Function of the hepatic remnant was estimated before surgery using radioactivity in fusion images of both liver single-photon emission computed tomography and computed tomography scans using (99m)Tc-labelled diethylene triamine penta-acetate-galactosyl-human serum albumin. RESULTS: All three patients with an ASGP-R concentration below 400 nmol/l and preoperative total amount of receptor in the future remnant liver (R0-remnant) of less than 53.0 nmol per liver died. Two patients with chronic hepatitis and R0-remnant values between 53.0 and 65.0 nmol per liver and a receptor concentration lower than 600 nmol/l developed liver dysfunction. The incidence of liver failure decreased inversely with increasing R0-remnant value. CONCLUSION: A combination of receptor concentration and the amount of hepatic receptor in the future liver remnant as detected on fusion images is useful in evaluating the risk of postoperative liver failure.

Preoperative evaluation of hepatic functional reserve following hepatectomy by technetium-99m galactosyl human serum albumin liver scintigraphy and computed tomography.

It is extremely important to have a good grasp of the acceptable limit of hepatectomy before operation because postoperative liver failure can take a fatal course; however, baseline data on the limit of hepatectomy have not been clearly defined. We therefore evaluated and compared the predicted remnant liver function obtained by computed tomography(CT) and technetium-99m diethylenetriamine penta-acetic acid-galactosyl human serum albumin (99mTc-GSA) liver scintigraphy in order to obtain precise data regarding remnant liver function before hepatectomy. We investigated 20 patients undergoing hepatectomy using the clearance rate of indocyanine green (KICG) as a parameter, and compared the predicted postoperative KICG obtained by CT and by transaxial single-photon emission tomographic (SPET) images acquired by 99mTc GSA liver scintigraphy before hepatectomy. In GSA studies, based on time-activity curves for the heart and liver, we compared HH15 (heart activity at 15 min divided by heart activity at 3 min), LHL15 (liver activity at 15 min divided by heart plus liver activity at 15 min) and KL (obtained from the time-activity curve for the liver) in 103 patients. In 58 patients without increased serum bilirubin, KL was compared with KICG. In four patients, occlusion of the right portal vein was performed with the aim of carrying out secondary hepatectomy, and changes in liver volume were compared between CT and 99mTc GSA liver scintigraphy. The correlation coefficient between the postoperative KICG predicted by CT and the actual postoperative KICG was rather poor, at r = 0.569 (P < 0.05); that between the postoperative KICG predicted by 99mTc GSA liver scintigraphy and the actual postoperative KICG was good, at r = 0.788 (P < 0.01); correlations between KL and HH15 and between KL and LHL15 in 103 patients were very good or good, at r = 0.906 (P < 0.001) and r = 0.807 (P < 0.001), respectively, and that between KL and KICG in 58 patients was very good, at r = 0.916 (P < 0.001). In all four cases of right portal vein occlusion, the remnant liver volume ratio was markedly increased after occlusion in GSA compared with CT, and the postoperative KICG predicted by GSA after occlusion was closer to the actual postoperative KICG than that predicted by CT. It is concluded that 99mTc GSA liver scintigraphy is useful for predicting remnant liver function before hepatectomy and for evaluating changes in regional liver function after occlusion of the portal vein unilaterally.

mRNA expression of matrix metalloproteinases and tissue inhibitors of metalloproteinase in interface tissue around implants in loosening total hip arthroplasty.

Matrix metalloproteinases (MMPs) and tissue inhibitors of metalloproteinase (TIMPs) play an important role in tissue destruction and remodeling. Nine samples of cement interface tissues from nine patients who had failed cemented total hip arthroplasty (THA) were obtained for revision of THA and analyzed on mRNA expression of MMPs and TIMPs. The preoperative serial radiographic examinations revealed an apparent clear zone around all implants. We excluded septic loosening as one of the factors affecting THA. Three samples were obtained from three different sites of the acetabular interface tissue in each patient. After extraction of total RNA from 27 samples, we used the reverse-transcriptional polymerase chain reaction (RT-PCR). mRNA of MMP-1, -2, -3, -9, and TIMP-1 and -2 was detected in the interface tissue. MMP-10 mRNA was not detected, yet MMP-1 and MMP-3 mRNA were commonly observed. TIMP-2 mRNA was also strongly expressed compared to TIMP-1. It was thus demonstrated that MMPs and TIMPs were produced locally in the cemented tissue of THA loosening. These findings may suggest that MMPs and TIMPs expressed around the implants play a critical role in the progression of aseptic loosening of THA.

[One stage operation for dead space of pyogenic and tuberculous osteomyelitis].

Pyogenic and tuberculous osteomyelitis is known to have difficult surgical problems. Complete surgical excision of dead and grossly infected soft tissues and osseous structures frequently results in large defects. Hydroxyapatite filler has been used to pack osteomyelitic defects. Between 1984 and 1991 we have treated 6 foci in 6 patients: 4 males aged 61, 54, 47 and 26 and; 2 females aged 59 and 36 years. There were 3 cases of chronic osteomyelitis, and one each of acute osteomyelitis, tuberculous osteomyelitis, and Brodie's abscess. All were reviewed within a period of between 21 to 94 months postoperatively. The pathogens cultivated were Mycobacterium tuberculosis in case 2 and Staphylococcus aureus in case 3 and case 6. In other cases, cultures revealed no pathogens. The hydroxyapatite fillers were mixed with an antibiotic. In addition, in the last four cases the fibrin sealant and CaCl2-thrombin solution were mixed. The excavated bone defect was packed with this composite biomaterial. Neither closed irrigation/suction using antibiotic solution nor a cast was used. Antimicrobial therapy directed specifically to the deep tissue specimens, was administered to all patients. On examination, all of the foci had completely healed by the end of the follow-up period. The cure of pyogenic and tuberculous osteomyelitis is obtained from obliterating dead spaces, which prevent the survival of organisms. Hydroxyapatite is the biomaterial most compatible with human bone and is also suitable for obliterating dead space. The advantages of the fibrin sealant system are that defects can be packed without gaps. Thus, postoperative hematomas can be avoided. In addition, the antibiotic incorporated into the fibrin sealant is released more slowly from the concentrated fibrin than from hematomas. As a result, pathogens multiply more slowly in fibrin. From these findings, we believe that this new method is simple, can be performed safely in one stage, and offers satisfactory results.

Bone incorporation of frozen femoral head allograft in revision total hip replacement.

Since 1983, 60 patients (60 joints) with acetabular bone loss underwent the total hip reconstruction using frozen femoral head allografts. Every 6 months, antero-posterior view radiographs of bilateral hip joints and sequential 99mTcMDP bone scintigrams were obtained. A CT scan of bilateral hip joints was taken to measure the volume of allograft. Bone incorporation was observed in 52 patients with an average time of 28.2 months. Bone scintigraphy also revealed that the uptake became normal 2-3 years after the revision. Differences in the time necessary for bone incorporation could be attributed to the size of allografts--the larger the volume, the longer the time required (p < 0.01). It was also found that on the side that received a transplant, the allograft was incorporated faster when there was more bone tissue surrounding the missing part of the acetabulum (p < 0.05).

The treatment of intracapsular hip fractures with total hip arthroplasty in rheumatoid arthritis.

Total hip arthroplasty was performed on 41 patients with rheumatoid arthritis for 43 intracapsular hip fractures from 1971 to 1989. Followup, observation of clinical signs, and radiographs were conducted between one to ten years. Of the 41 patients, 25 had died by the end of the study. Total hip arthroplasty was found to be effective in relieving joint pain, and the walking ability of patients generally recovered to pre-injury status following the operation. Some patients experienced deterioration of the knee and ankle joints due to rheumatoid arthritis, and in such cases there was progressive loss of walking ability. Nevertheless, the function of the hip joint was well preserved, and most patients reported that pain had disappeared and the joint range of motion had returned to normal. In only one case was revision surgery necessary. There was little overall loosening of prostheses, and there were no problems concerning the durability of the artificial joint. The presence, therefore, of femoral neck fractures in patients with rheumatoid arthritis, who are to be encouraged to get out of bed and begin walking as soon as possible, is a strong indication for total hip arthroplasty.

[Clinical usefulness of the measurement of type-II procollagen carboxypeptide (C-II propeptide, pColl-II-C) in synovial fluid as a marker of collagen metabolism in cartilage].

Type-II procollagen-C-peptide (pColl-II-C) in synovial fluids was studied in 319 patients with osteoarthritis (OA; 151), rheumatoid arthritis (RA; 141), traumatic arthritis (TA; 27) and 15 healthy volunteers using the newly developed ELISA kit. The mean levels of pColl-II-C in synovial fluids of healthy controls, OA, TA, and RA were 0.3 +/- 0.1 ng/ml, 5.9 +/- 0.3 ng/ml, 6.8 +/- 1.4 ng/ml and 1.1 +/- 0.1 ng/ml, respectively. pColl-II-C levels in synovial fluids of OA and TA were significantly higher compared to those of healthy controls and RA. It was also demonstrated that pColl-II-C levels could reflect the quantitative and qualitative change of cartilage metabolism. Therefore, the quantification of this molecule in synovial fluid could be beneficial to know the synthetic activity of type II collagen of chondrocytes, since pColl-II-C is a part of the precursor molecule of type II collagen.

[Assessment of right ventricular afterload in mitral valve diseases with radionuclide angiography].

Right ventricular function at rest and during exercise was studied in 33 patients with mitral valve disease by equilibrium gated radionuclide angiography using 99mTc in vivo labeled red blood cells. Radionuclide measurements of right ventricular ejection fraction (RVEF) were correlated with mean pulmonary arterial pressure (mPAP). RVEF decreased significantly with exercise. There was no significant correlation between RVEF at rest and mPAP. However, mPAP showed significant negative correlation with RVEF during exercise and with the changes of RVEF from rest to exercise. It is concluded that RVEF during exercise in mitral valve disease is affected by right ventricular afterload, and the measurements of RVEF at rest and during exercise by equilibrium gated radionuclide angiography is useful to assess right ventricular afterload.

[A new application of bull's-eye analysis to lung perfusion scintigraphy].

Technetium-99m macroaggregated albumin lung perfusion scintigraphy was performed and evaluated semiquantitatively by bull's-eye analysis in 24, including 7 with central pulmonary carcinoma, 3 with hypersensitivity pneumonitis (HP), 3 with diffuse panbronchiolitis (DPB) and 11 normal subjects. First, whole lung field was divided into three regions by three concentric circles. And then radial axes were projected from the center to define 36 sectors, 10 degree each. The counts of each sector was calculated and bull's-eye image and circumferential profile curve were displayed. The patient's map was compared with the lower limit of normal (mean-2 SD), and the extent score (ES) and the severity score (SS) were calculated. The ES was 0.25 +/- 0.12 in pulmonary carcinoma (n = 7), 0.08 +/- 0.07 in HP (n = 3), 0.06 +/- 0.04 in DPB (n = 3). The SS was 26.39 +/- 15.17 in pulmonary carcinoma, 4.75 +/- 5.57 in HP, 4.29 +/- 3.67 in DPB. In one case of central pulmonary carcinoma, segmental perfusion defect was evaluated semiquantitatively by bull's-eye image and circumferential profile curve. And in one case of HP, the change of regional pulmonary blood flow could be followed easily using extent and severity map. This new application of Bull's eye analysis to lung perfusion scintigraphy might be useful to evaluate regional pulmonary blood flow.

Studies of left ventricular volume estimation from gated blood pool scan with the use of regression equations.

The authors carried out experimental and clinical studies of left ventricular volume measurement using equilibrium-gated blood pool scan. Using phantoms, we experimentally obtained a regression equation between radioisotope levels and camera counts. From this equation, we deduced a regression equation between camera counts and volumes, which was then used for calculation of left ventricular volumes using count technique. In an experiment using phantom with various volumes, we obtained a favorable result that the average absolute error between the true and measured volumes was as small as 6.8%. In 11 patients, we calculated the left ventricular volume and ejection fraction employing the regression equation and compared the calculated values with the values obtained by cinemascopy. This comparison disclosed an excellent correlation (r = 0.955 for end-diastolic volume, 0.997 for end-systolic volume and 0.853 for ejection fraction). Mean absolute error was 16.2% for end-diastolic volume and 16.0% for end-systolic volume. These results indicate that this technique is clinically applicable.

[Study of quantitative evaluation of liver volume and accumulation rate of radioactive agent with single photon emission computed tomography].

The quantitative evaluation on measurement of liver volume and the hepatic accumulation rate of the radioactive agent were studied with respect to body constitution, background activity and splenic consumption rate, using single photon emission computed tomography (SPECT). The optical cut-off level for liver volume determination was proved to be reasonable as 35%. The background less than 5% had no influence to their clinical estimation with the error of less than 1.6%. The estimation of liver volume was mostly influenced by the splenic activity. When the splenic activity was increased two times of the hepatic activity, the liver volume was determined as 4.2% larger. Calculated counts by SPECT was well correlated with the hepatic activity. This study proved that SPECT was useful for the quantitative evaluation of the liver volume and the hepatic accumulation rate.