The impact of self-efficacy for physical activity on health-related quality of life in total knee arthroplasty recipients.

BACKGROUND: Some patients with end-stage osteoarthritis of the knee remain unsatisfied after total knee arthroplasty (TKA). We postulated that to increase satisfaction, self-efficacy (SE) for physical activity should receive more attention in rehabilitative intervention, alongside the management of patient expectations, pain, and function. OBJECTIVE: We examined the relative impact of Physical Activity SE on Health-Related Quality of Life (HRQOL) alongside other factors such as pain and physical function which are well-addressed by current interventions. METHODS: One hundred and six first-TKA recipients (15 Male/91 Female, age 73.6 ± 7.2) were evaluated at 3 and 6 months post-operatively using the Medical Outcomes Study 36-Item Health Survey (SF-36v2) for HRQOL, knee extension strength measurement, Timed Up and Go test (TUG), One Leg Standing time test (OLS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) for pain and function, and an instrument for measuring Physical Activity SE among the frail elderly in Japan. RESULTS: Significant improvement over pre-operative values was found at 3 and 6 months in TUG, OLS, WOMAC Pain and Function, and the 8 subscales of the SF-36v2. Factors found to significantly impact SF-36v2 subscale scores at 6 months post-operatively were found to be knee pain, knee function, and SE for physical activity. CONCLUSION: These results support our postulation that interventions to improve SE for physical activity could have comparable impact alongside interventions for knee pain and knee function, on the advancement of HRQOL among TKA recipients.

Timing of resection for synchronous liver metastases from colorectal cancer.

BACKGROUND: This study aimed to compare the surgical outcome and long-term survival between simultaneous and delayed resection of liver metastases from colorectal cancer (LM), and to identify the factors influencing hepatic disease-free survival in patients with synchronous LM. METHODS: Seventy-four patients with LM were divided into two groups, i.e., 32 patients who underwent hepatectomy at the time of colorectal surgery (simultaneous group) and 42 patients who underwent delayed liver resection (delayed group). RESULTS: The hepatic disease-free survival rates of patients from the delayed group with either ≥ 3 or <3 liver metastases were significantly better than that of the simultaneous group. Multivariate analysis showed that simultaneous resection was one of three independent prognostic indicators with an influence on hepatic disease-free survival. In 13 of the 42 (31%) patients from the delayed group, new metastatic lesions were found in the same and/or different segments after re-evaluation during the interval between operations. These patients had a higher incidence of poorly differentiated or mucinous adenocarcinoma, shorter interval between procedures, and larger tumors than patients without tumor progression. CONCLUSIONS: Tumor progression could be recognized and occult metastases were detected during the interval between operations. Delayed resection of synchronous LM may be useful to reduce the risk of rapid recurrence in the remnant liver. Patients with poorly differentiated or mucinous adenocarcinoma and those with larger tumors who undergo delayed liver resection should receive neoadjuvant chemotherapy during the interval between operations.

[Hepatic resection after neoadjuvant therapy for initially unresectable colorectal liver metastases].

BACKGROUND: Recently, an increased number of reports have been published on liver resection following neoadjuvant chemotherapy ( NAC) in patients with initially unresectable colorectal liver metastases (IUCLM). However, the definition of unresectable liver metastases differs among institutions. The size of liver tumor B5 cm and number of tumors B5 is commonly a contraindication for resection of liver metastases. The present study was performed to compare the short and longterm results between patients who underwent liver resection following NAC for IUCLM and those with multiple bilobar metastases for initially resectable liver metastases. METHODS: Twenty-seven patients with multiple bilobar liver metastases between 1994 and 2007 were divided into two groups, i. e. 11 patients who underwent liver resection following NAC for IUCLM and 16 patients who initially underwent liver resection. NAC was used in three in J-IFL and eight cases in mFOLFOX6. RESULTS: All eleven patients with IUCLM were H3/grade C. The median course of NAC was 6 (4-6 courses, Mean+/-SD: 6+/-2 courses). The objective overall response rate was 100% (11/11). H3 of eleven patients was changed to two in H1 and nine in H2 after chemotherapy. Grade C of 11 patients was down-staged in 4 in grade Band 2 in grade A. The H factors and grade of 16 patients who initially underwent liver resection were H16H28H32 and grade A4/B6/C6, respectively. The disease-free and overall survival after resection of colorectal liver metastases between patients with initially unresectable and resectable liver metastases were not significantly different. CONCLUSIONS: NAC enables liver resection in some patients with IUCLM. It should be performed not only preoperatively but also postoperatively for IUCLM because of better survival after surgery.

Risk factors and outcome of early recurrence after resection of small hepatocellular carcinomas.

BACKGROUND: This study aimed to clarify risk factors for early recurrence and examine the subsequent outcome in patients undergoing potentially R0 resection of small hepatocellular carcinomas (HCCs) (

Hepatic resection for hepatocellular carcinoma in the elderly.

BACKGROUND AND OBJECTIVES: Aging of the population has significantly increased the number of elderly patients undergoing surgery for hepatocellular carcinoma (HCC). We aimed to compare the results of hepatectomy for HCC in patients >/=70 years old with those for younger patients. METHODS: Clinicopathological data and outcomes for 155 elderly patients and 333 younger patients with HCC who underwent hepatectomy between 1992 and 2007 were retrospectively compared. RESULTS: The elderly group had a higher incidence of associated diseases, but had better preoperative liver function. Although postoperative delirium was more common in the elderly group, there were no significant differences between the two groups with regard to operative morbidity, hospital death, disease-free survival, and overall survival. The overall recurrence rate was significantly higher in the elderly patients with alcohol abuse than in younger patients with alcohol abuse. Multivariate analysis revealed that preoperative alcohol abuse was a prognostic factor for elderly patients. CONCLUSIONS: The short-term and long-term outcomes of surgery for HCC were similar in elderly and younger patients. Elderly patients with preoperative alcohol abuse should be followed closely, even after R0 surgery, because alcohol abuse is strongly correlated with postoperative recurrence and worse survival.

HA/GSA-Rmax ratio as a predictor of postoperative liver failure.

BACKGROUND: Postoperative mortality after hepatectomy remains high compared with other types of surgery in patients who have cirrhosis or chronic hepatitis. Although there are several useful perioperative markers of liver dysfunction, there are no standard markers for predicting postoperative liver failure. This study investigated risk factors for postoperative liver failure after resection of hepatocellular carcinoma to detect markers that could identify candidates for hepatectomy. METHODS: Perioperative risk factors for liver failure after hepatectomy were analyzed in 191 patients with hepatocellular carcinoma. Multivariate logistic regression analysis was done to investigate factors with a significant independent influence among 35 variables. The ratio of serum hyaluronic acid to the maximum removal rate of technetium-99 m diethylenetriaminepentaacetic acid galactosyl human serum albumin (hyaluronate/GSA-Rmax ratio) was calculated. RESULTS: Liver failure occurred postoperatively in 16 patients, 3 of whom died. The hyaluronate/GSA-Rmax ratio was a risk factor for postoperative liver failure by univariate analysis and was the only risk factor according to multivariate analysis. All three patients who died had a hyaluronic acid/GSA-Rmax ratio > or = 500 mg min/dl. This ratio had a sensitivity of 88% and a specificity of 92% for predicting liver failure. CONCLUSIONS: To reduce postoperative liver failure, preoperative planning should employ various measures of the hepatic functional reserve, including tests of both parenchymal and nonparenchymal liver function. The hyaluronate/GSA-Rmax ratio can predict liver failure after hepatectomy, and a ratio > or = 500 mg min/dl is a relative contraindication to liver resection.

Impact of fresh frozen plasma on hepatectomy for hepatocellular carcinoma.

BACKGROUND: Little is known about the effect of transfusing fresh frozen plasma on the outcome after hepatectomy for hepatocellular carcinoma. PATIENTS AND METHODS: Among 410 patients who underwent curative resection between 1992 and 2005, 180 patients had perioperative transfusion with whole blood or packed red blood cells and fresh frozen plasma (group A), while 46 patients were only transfused with packed red cells (group B), 43 patients were only transfused with fresh frozen plasma (group C) and 141 patients had no transfusion (group D). RESULTS: Group C had significantly fewer postoperative complications and a shorter hospital stay than group A. Preoperative coagulation was significantly worse in group C. Survival was significantly better in groups C and D than in group A. CONCLUSION: Perioperative transfusion of fresh frozen plasma improves clotting factors without an adverse influence on the survival of patients with liver dysfunction undergoing resection of hepatocellular carcinoma.

Risk factors for early death due to recurrence after resection of large hepatocellular carcinomas.

BACKGROUND/AIM: Long-term survival after resection of hepatocellular carcinomas larger than 5 cm in diameter is worse than after resection of smaller tumors. The risk factors for early death due to recurrence after resection of large tumors have not been clearly elucidated. METHODOLOGY: Among 377 patients who underwent curative resection of hepatocellular carcinoma between 1992 and 2004, 115 patients with tumors larger than 5 cm in diameter were enrolled. They were divided into two groups, i.e., 35 patients who died of recurrent cancer within 2 years after surgery and 80 patients who survived for more than 2 years. RESULTS: The preoperative serum alpha-fetoprotein level, positive surgical margins, number of tumors, the serum levels of albumin and alpha-fetoprotein at 1 and 3 months after surgery, as well as the prothrombin time, cholinesterase and protein induced by vitamin K antagonism-II levels at 3 months, respectively, were significant determinants of survival by univariate analysis. Multivariate analysis showed that an albumin level <3.5 g/dl at 1 month and a cholinesterase level <100 U/L at 3 months after surgery were associated with an increased risk of early death due to recurrence. CONCLUSIONS: The hepatic functional reserve in the early postoperative period significantly influences early recurrence and early death after resection of large hepatocellular carcinomas. It is important to maintain a good perioperative nutritional status and early postoperative adjuvant therapy is required for patients with large tumors.

Liver regeneration in donors evaluated by Tc-99m-GSA scintigraphy after living donor liver transplantation.

The impact of hepatic steatosis on regeneration of the remnant liver after living donor liver transplantation is unclear. We evaluated the impact of steatosis on regeneration and function of the remnant liver by using technetium-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy. Twelve living donors were classified into groups with or without mild hepatic steatosis according to the liver-to-spleen attenuation ratio on computed tomography: 6 donors had a ratio >or= 1.20 (control group) and 6 donors had a ratio < 1.20 (fatty liver group). Scintigraphy was performed to determine the hepatic uptake ratio of the tracer (corrected for disappearance from the blood) and the maximum removal rate of the tracer by hepatocytes as parameters of the hepatic functional reserve. The fatty liver group had a significantly lower corrected hepatic uptake ratio and removal rate compared with the control group at 6 and 12 months after partial hepatectomy. These parameters were decreased at 1 month after surgery in both groups. However, both parameters returned more rapidly to prehepatectomy levels in the control group. The regenerated liver volume estimated by scintigraphy did not differ significantly between the two groups at any time. Liver scintigraphy may be useful for evaluating the regeneration of functioning hepatocytes. Because donors with mild hepatic steatosis showed impaired liver regeneration at 1 year after partial hepatectomy, management of these donors requires more care.

Risk factors for different patterns of recurrence after resection of hepatocellular carcinoma.

BACKGROUND: Long-term survival of patients with hepatocellular carcinoma after hepatectomy is unsatisfactory because of the high recurrence rate. PATIENTS AND METHODS: Among 396 patients who underwent curative resection of hepatocellular carcinoma, there were 228 patients with clinical recurrence: 85 with solitary intrahepatic recurrence (group A), 109 with two or more intrahepatic recurrences (group B), and 34 who had extrahepatic recurrence (group C). The clinical and pathological factors for each group were investigated for association with long-term survival of each group. RESULTS: The survival rate of group C was significantly lower than that of the other groups. Patients in group C were significantly younger than those in groups A or B, with higher levels of protein induced by absence/antagonism of vitamin K-II, larger tumors, more poorly differentiated tumors, intravascular invasion and a lower incidence of cirrhosis than the other groups. Group A showed a significantly longer period until recurrence and maintained good liver function at recurrence. In group B, the survival rate of Child-Pugh class A patients was significantly higher than that of class B and C patients. Class A patients received significantly more treatments for recurrence than patients in the other classes. CONCLUSION: Postoperative adjuvant chemotherapy should be performed as early as possible after hepatectomy if the patient is younger, has a large tumor and/or has a high level of protein induced by absence/antagonism of vitamin K-II. Patients with solitary intrahepatic recurrence and adequate liver function should receive further curative therapy. It is important to maintain the postoperative nutritional status of patients with multiple intrahepatic recurrences in order to allow repeated and aggressive therapy to be performed.

A review of the prognostic factors in patients with recurrence after liver resection for hepatocellular carcinoma.

BACKGROUND: Liver transplantation achieves better results when hepatocellular carcinoma fits the Milan criteria. This study investigated predictors of recurrent hepatocellular carcinoma exceeding the Milan criteria. METHODS: Among 285 patients with hepatocellular carcinoma fitting the Milan criteria who underwent curative resection, 143 patients suffered initial recurrence (92 had tumors fitting the criteria) and 71 patients suffered a second recurrence (40 conforming tumors). RESULTS: Survival after hepatectomy was significantly worse when initial recurrence was nonconforming. Similarly, survival after initial recurrence was significantly worse when the second recurrence was nonconforming. A preoperative increase of protein induced by vitamin K absence/antagonist II, a tumor diameter of 3 cm or greater, age of 65 years or younger, and intraoperative blood transfusion increased the risk of nonconforming initial recurrence. CONCLUSIONS: Liver transplantation should be considered initially for younger patients with hepatocellular carcinoma fitting the Milan criteria, larger tumors, and an increase of protein induced by vitamin K absence/antagonist II.

Influence of transcatheter arterial chemoembolization on the prognosis after hepatectomy for hepatocellular carcinoma in patients with severe liver dysfunction.

BACKGROUND: The influence of preoperative transcatheter arterial chemoembolization (TACE) on postoperative survival and recurrence of hepatocellular carcinoma (HCC) after resection is still controversial. The effect of preoperative TACE on the prognosis of HCC after hepatectomy in 243 patients with liver dysfunction was evaluated. MATERIALS AND METHODS: Among 243 patients who underwent curative resection of HCC between 1992 and 2005, 124 patients had an indocyanine-green retention rate at 15 min (ICGR15) of <17% (49 underwent TACE), while 119 patients had an ICGR15 of > or =17% (66 underwent TACE). The clinical characteristics, operative results and long-term survival were compared between patients with and without preoperative TACE who had mild or severe liver dysfunction. RESULTS: There was no significant difference in the recurrence-free and overall survival rates between the TACE and no TACE groups with an ICGR15 <17%. Among the 119 patients with an ICGR15 > or =17%, there were no significant differences of preoperative characteristics, operative findings, or histology between the two groups. However, the post-resection disease-free and overall survival rates of 66 patients who underwent TACE were significantly better than those of 53 patients who did not have TACE (p = 0.009 and p = 0.0099, respectively). Using multivariate analysis, preoperative TACE was independently associated with better disease-free and overall survival after resection in patients with an ICGR15 > or =17% (p = 0.0309 and p = 0.0162, respectively). CONCLUSION: Preoperative TACE did not alter the prognosis after resection of HCC in patients with mild liver dysfunction, but it did improve the prognosis of patients with severe liver dysfunction.

Recurrent hepatitis C after living donor liver transplantation detected by Tc-99m GSA liver scintigraphy.

Recurrence of hepatitis C virus (HCV) after living donor liver transplantation was investigated using technetium-99m- diethylenetriaminepentaacetic acid-galactosyl human serum albumin (Tc-99m-GSA) liver scintigraphy. Four patients with decompensated cirrhosis due to HCV infection were retrospectively reviewed in this study. Scintigraphy was performed to determine the hepatic uptake ratio of the tracer corrected for disappearance from the blood, as well as the maximal removal rate of the tracer by hepatocytes, as parameters of hepatic functional reserve. In all patients, serum HCV ribonucleic acid (RNA) was detected 3 months after transplantation. The corrected hepatic uptake ratio and removal rate showed little change after transplantation in two patients without the recurrence of HCV infection. In another two patients, these levels were decreased at 3 months after transplantation. In one patient, recurrent HCV infection was diagnosed by confirmatory histologic examination at 12 months after transplantation. In the other patient, both levels declined further at 8 months. Although treatment was initiated with a combination of interferon plus ribavirin, this patient died of progressive hepatic failure. In conclusion, a decrease in scintigraphic parameters at 3 months after transplantation suggests recurrent HCV infection affecting the graft. Tc-99m-GSA liver scintigraphy is a useful noninvasive method for evaluating graft functional reserve.

Infrarenal abdominal aortic aneurysm complicated by persistent endotension after endovascular repair: report of a case.

Endoleak and endotension may prevent the successful exclusion of an aneurysm after endovascular aortic aneurysm repair (EVAR). The pressurization in the excluded aneurysm sac caused by endotension may lead to rupture of the aneurysm; however, the cause of endotension and its underlying mechanisms remain unclear. We report a case of infrarenal abdominal aortic aneurysm (AAA) complicated by persistent endotension after EVAR. Although no endoleaks were found on conventional double-phase computed tomographic scans, a thrombosed endoleak existed in the side branch and attachment site of the endograft. After treating the undetectable thrombosed endoleaks, physical examination revealed that the pressure of the excluded aneurysm had diminished, with shrinkage of the aneurysm. This case report suggests that a high-pressure undetectable type I or type II endoleak could be a major cause of endotension. Thus, postoperative evaluation of the attachment site of an endograft is important after EVAR.

Protective effect of fibronectin for endotoxin-induced liver injury after partial hepatectomy in rats.

BACKGROUND: Endotoxemia may occur after hepatectomy and become the cause of post-operative death. Fibronectins (Fns) are involved in a number of biological processes, such as cellular adhesion, motility, differentiation, apoptosis, hemostasis, wound healing, and ischemic injury. Studies were performed to determine whether Fn influences the survival rate of rats subjected to endotoxin-induced liver injury after partial hepatectomy. MATERIALS AND METHODS: Lipopolysaccharide (LPS) was administered intravenously to male Sprague-Dawley rats within 48 h of 70% hepatectomy. Before LPS administration, plasma Fn or bovine serum albumin was given intravenously. RESULTS: The survival rate of the Fn-treated group was markedly improved compared with that of the controls. Fn prevented increases in the concentrations of serum enzymes and total bilirubin related to liver injury. The levels of inflammatory cytokines, including tumor necrosis factor-alpha, interleukin-1beta, and cytokine-induced neutrophil chemoattractant, in serum and liver tissue, also were significantly lower in the Fn-treated group than in the control group. Furthermore, the degree of apoptosis and necrosis in remnant liver was significantly decreased in the Fn-treated rats compared with the controls. CONCLUSIONS: These results indicate that Fn prevents endotoxin-induced liver injury after partial hepatectomy, at least in part through the inhibition of production of inflammatory cytokines, necrosis and apoptosis in the remaining liver.

Genetic alterations in normal epithelium of colorectal cancer patients may be a useful indicator for subsequent metachronous tumor development.

BACKGROUND: We attempted to identify areas of microsatellite alterations specific to histologically normal colorectal epithelium and to clarify the correlations among those molecular events and clinicopathologic features. METHODS: We conducted a prospective observation study on 51 colorectal cancer patients. Preoperative blood and microdissected histologically normal colorectal epithelium and neoplastic tissues were collected. Microsatellite analyses with seven microsatellite loci were performed to examine the genetic potential of individual tumors and histologically normal colorectal epithelium. RESULTS: In the sporadic colorectal cancer group, p53 LOH in the neoplastic epithelium had a significant correlation with the maximum tumor diameter and the preoperative serum cancer antigen 19-9 level, but not with the depth of invasion of the primary tumor. Among the patients who had p53 LOH in the histologically normal colorectal epithelium, four additional tumors were discovered within 30 months after curative surgery. For those patients, microsatellite alterations in normal colorectal epithelium were more sensitive than tumor markers. CONCLUSIONS: For accurate LOH analysis, nonmalignant lymphocytes from blood should be used as the appropriate normal DNA sample. Focusing on the identification of high-risk patients for microsatellite alterations in histologically normal colorectal epithelium can be a useful indicator of subsequent metachronous tumor development after colorectal surgery. For accurate LOH analysis, nonmalignant lymphocytes from blood should be used as the appropriate normal DNA sample. Focusing on the identification of high-risk patients for microsatellite alterations in histologically normal colorectal epithelium can be a useful indicator of subsequent metachronous tumor development after colorectal surgery.

Microsatellite analysis of fecal DNA for colorectal cancer detection.

BACKGROUND AND OBJECTIVES: The advent of noninvasive methods of testing for colorectal cancer that have a high level of specificity and sensitivity is eagerly awaited. METHODS: Thirty patients with sporadic colorectal cancer and 11 patients with hereditary nonpolyposis colon cancer (HNPCC) enrolled in this study. We analyzed the loss of heterozygosity (LOH) in matched genomic DNA extracted from blood and surgical specimens (tumor and tumor-free colonic mucosa), and the corresponding oral rinse and stool specimens using seven microsatellite loci (APC, p53, DCC, hMLH1, D9S162, D9S171, and IFNA). To reduce the normal colonocyte DNA contamination of the stool samples, we compared three different methods for fecal genomic DNA extraction. As normal controls, we analyzed the LOH using the oral rinse and stool samples from 15 individuals without cancer. RESULTS: The LOH determined from the oral rinse and the stool samples matched those determined from the blood and the neoplastic tissue. All patients with HNPCC had microsatellite alterations at hMLH-1 in tumor DNA and corresponding fecal DNA. There were significant differences in the frequency of p53-LOH and D9S171-LOH between the group with sporadic disease and those with HNSCC (P = 0.0031 and 0.0294, respectively). Two cases with D9S162-LOH were detected in individuals without cancer. For the patients with sporadic disease, using p53 and adenomatous polyposis coli (APC), the sensitivity of the fecal DNA analysis was 96.7% (95% CI, 83-100) with a specificity of 100%. CONCLUSION: We demonstrate that LOH analysis using oral rinse and stool samples may be a suitable screening tool for colorectal cancer.