Poor postoperative blood glucose control increases surgical site infections after surgery for hepato-biliary-pancreatic cancer: a prospective study in a high-volume institute in Japan.

Two hundred and sixty-five consecutive patients awaiting hepato-biliary-pancreatic surgery were prospectively observed for surgical site infections (SSIs). SSI rates differed according to type of hepato-biliary-pancreatic surgery. Multivariate analysis identified enteric anastomoses, poor postoperative blood glucose control and type of cancer as independent risk factors. SSI rates were directly correlated with the degree of hyperglycaemia encountered during the postoperative period. In particular, SSI rates were 5/25 (20%) among patients in whom a blood glucose level of <200mg/dL was maintained by insulin infusion therapy, which was significantly better than the rates of 49/94 (52%) among patients in whom a blood glucose level of <200mg/dL was not maintained despite insulin infusion therapy (P<0.01). It is necessary to maintain postoperative blood glucose levels of <200mg/dL in order to reduce SSI rates.

Multidrug resistance gene (MDR-1) expression as a useful prognostic factor in patients with human hepatocellular carcinoma after surgical resection.

BACKGROUND: Multidrug resistance gene (MDR-1) overexpression has been correlated with tumor aggressiveness and worse prognosis in some human neoplasms. The aim of this study is to evaluate the clinical value of MDR-1 mRNA expression as a prognostic factor after surgical resection in human hepatocellular carcinoma (HCC). METHODS: MDR-1 mRNA levels in tissue samples from 34 patients with HCC, who underwent surgical resection, were measured by quantitative northern blot analysis. We stratified these patients into two groups according to a ratio of MDR-1 mRNA levels of HCC to nontumorous tissue; MDR-1 mRNA ratio > or = 1.0 and < 1.0. The overall and disease-free survival rates were analyzed using multivariate regression analysis. RESULTS: The median survival periods were 10.3 and 35.8 months for patients with the MDR-1 mRNA ratio > or = 1.0 and < 1.0, respectively, and the corresponding 5-year survival rates were 33 and 54%, respectively, P < 0.05. The multivariate analysis revealed that TNM stage and MDR-1 mRNA ratio were independent factors for predicting overall survival after surgical resection. CONCLUSION: This study suggested that the measurement of the MDR-1 mRNA levels in HCC and nontumorous liver tissue might be a useful prognostic factor after surgical resection in patients with HCC.

Benefits and limits of hepatic resection for gastric metastases.

BACKGROUND: The significance of hepatic resection for gastric metastases has been controversial. METHODS: Forty consecutive patients undergoing hepatic resection for gastric metastases were reviewed to examine the benefits and the limits of hepatic resection using univariate and multivariate analyses. RESULTS: The overall survival was 27% at 2 years, 18% at 5 years, and 11% at 10 years. Six patients survived more than 5 years. All of the 6 patients underwent anatomical hepatic resection more extensive than segmentectomy, with sufficient resection margin. There were recurrences in 31 patients, and 94% of the recurrences were in the remaining liver. Univariate analysis showed time of hepatic metastases (P = 0.0078) and resection margin (P = 0.024) as significant prognostic factors. Multivariate analysis indicated that only time of hepatic metastases was an independent prognostic factor that influenced survival. CONCLUSIONS: These results suggest that in patients with synchronous metastases we should consider patient selection more strictly, and that in patients with metachronous metastases we should perform anatomical hepatic resection with sufficient resection margin.

Anti-inflammatory response in patients with obstructive jaundice caused by biliary malignancy.

BACKGROUND: Obstructive jaundice potentially modulates the host defense mechanism resulting in perioperative infection. It has been reported that a systemic inflammatory response occurs in patients with obstructive jaundice. An anti-inflammatory response was studied in 29 jaundiced patients undergoing biliary drainage. RESULTS: Plasma concentrations of interleukin (IL)-10, soluble tumor necrosis factor receptor (STNFR) p55, STNFR p75, IL-1 receptor antagonist (IL-1ra), IL-6 and soluble CD14 (sCD14) were measured by using immunoassay. Plasma concentrations of IL-10, STNFR p55, STNFR p75, IL-1ra, IL-6 and sCD14 were significantly higher in jaundiced patients than in the controls (P < 0.01). After biliary drainage, the concentrations of IL-10, the three cytokine antagonists, and IL-6 decreased significantly (P < 0.05). The sCD14 concentration did not decrease. At the time of drainage, the concentrations of STNFR p55 and STNFR p75 were significantly higher in 10 patients with positive bile cultures than in 19 patients with negative bile cultures (P < 0.05). Bile cultures became positive 14 days after drainage in 10 patients, and remained negative in nine. The concentration of STNFR p55 before drainage was significantly higher in the former group (P = 0.05). The plasma concentrations of IL-10 and STNFRs were significantly correlated with the IL-6 concentration, body temperature and the white blood cell count (P < 0.05). Serum total bilirubin levels did not affect plasma levels of anti-inflammatory mediators, and sCD14. CONCLUSION: Jaundiced patients exhibited an anti-inflammatory immune response that potentially modulates the host defense mechanism and results in anergy and increased susceptibility to infection. Biliary infection may be one of the major stimuli of the immune response.

Nonsurgical management of ruptured pseudoaneurysm in patients with hepatobiliary pancreatic diseases.

OBJECTIVE: Rupture of a pseudoaneurysm is an unusual complication after surgical and interventional treatments in patients with hepatobiliary pancreatic diseases. However, it occurs abruptly and often results in a lethal outcome. The aim of this study was to retrospectively analyze our experiences of cases of rupture of pseudoaneurysms for providing appropriate therapeutic planning. METHODS: Between 1985 and 1998, we observed ruptures of pseudoaneurysms in 14 of 910 patients with hepatobiliary pancreatic diseases--six after pancreaticoduodenectomy, three after hepatic resection, two after hepatopancreaticoduodenectomy, two after percutaneous transhepatic biliary drainage, and one after gastrojejunostomy. Thirteen of the 14 patients underwent emergency angiography and transcatheter arterial embolization (TAE) or infusion therapies, and one of the 13 patients underwent surgical hemostasis because of incomplete hemostasis with TAE. The other patient, who did not undergo emergency angiography, had surgical hemostasis initially. RESULTS: TAE achieved hemostasis in 11 of 13 patients (85%), but only incomplete hemostasis in the remaining two patients. Of these two patients, one underwent laparotomy, but died of multiple organ failure (MOF) at 6 days after surgical hemostasis. The other died at 1 day after emergency angiography. Ten of 11 patients who obtained complete hemostasis by means of TAE could later be discharged, but one patient died of liver failure, and/or MOF. One patient who underwent laparotomy initially without angiography died of MOF at 43 days after the operation. The onset of rupture of a pseudoaneurysm was a mean of 35.4 days (range 12-76) after surgical or interventional procedures. The warning prodromal symptoms were upper abdominal oppression, nausea, and backache before the rupture of pseudoaneurysms. Fever, leukocytosis. hyperbilirubinemia, anastomotic leak, and intraabdominal abscess were frequent persistent signs in these patients. CONCLUSIONS: If the warning prodromal symptoms appear in patients along with these persistent signs, the impending rupture of pseudoaneurysms should be suspected. Thereafter, a diagnostic angiography should be performed immediately to enable early diagnosis and embolization therapy for rupture of pseudoaneurysms when hemorrhagic episodes appear in these patients. Early detection and immediate embolization might bring about a favorable outcome in patients with hepatobiliary pancreatic diseases who encounter rupture of pseudoaneurysms after surgical and interventional treatments.

Mechanism of cold ischemia-reperfusion-induced graft injury after orthotopic liver transplantation in rats.

BACKGROUND/AIMS: The purpose of this study was to clarify the mechanism of cold ischemia-reperfusion-induced graft injury after liver transplantation, especially with regard to the relationship between hepatocyte, sinusoidal endothelial cell injury, and hepatic hemodynamic alteration. METHODOLOGY: We evaluated changes in hepatocyte and sinusoidal endothelial cell function, and hepatic hemodynamics after reperfusion in an isogeneic rat liver-transplantation model. The livers of male LEW rats were stored in 4 degrees C lactated Ringer's solution for 1 hr, 3 hr (viable graft), and 6 hr (nonviable graft) before implantation. After reperfusion, hepatocyte function was assessed by serum alanine aminotransferase level and bile output; sinusoidal endothelial cell function was evaluated by serum hyaluronic acid level. Furthermore, we measured hepatic venous oxygen saturation, and portal venous blood flow using a transit time blood flow meter. RESULTS: At 2 hr after reperfusion, the hepatocyte function was similar in all groups. However, the sinusoidal endothelial cell function deteriorated severely in the nonviable graft group, and significantly decreased hepatic venous oxygen saturation levels were observed, suggesting poor hepatic circulation. At 4 hr after reperfusion, the hepatocyte injury was markedly increased in the nonviable graft group. Although systemic blood pressure remained stable, significantly decreased portal venous blood flow in the nonviable graft group was found compared with the viable graft groups. Histopathological studies showed that massive ischemic necrosis was seen in zone III (central) of hepatic lobule 8 hr after reperfusion in the nonviable graft group. CONCLUSIONS: These data suggest that the sinusoidal endothelial cell injury was predominant in the early phase of reperfusion, and might cause microcirculatory disturbances, resulting in decreased portal venous blood flow. This phenomenon may subsequently cause ischemic damage to the hepatocyte, with eventual graft failure.

Effects of perioperative protease inhibitor on inflammatory cytokines and acute-phase proteins in patients with hepatic resection.

AIM: The objective of this study was to examine the effects of perioperative administration of ulinastatin, or urinary trypsin inhibitor (UTI), on inflammatory cytokines and acute-phase proteins induced by inflammatory cytokines in patients who had undergone hepatic resection. METHOD: Twenty patients admitted to the hospital for hepatic resection were equally randomized to one of two groups: the UTI group, those who were administered perioperative UTI, and the control group. RESULTS: The UTI group had no adverse effects from using UTI. Production of serum interleukin-6 (IL-6) tended to be attenuated in the UTI group when compared with the control group. Moreover, the UTI group had significantly decreased positive acute-phase C-reactive protein (p < 0.05) and significantly increased negative acute-phase protein prealbumin and retinol-binding protein (p < 0.05). Serum IL-6 levels significantly correlated with serum C-reactive protein levels on postoperative day 1 (r = 0.70, p < 0.01). CONCLUSION: These results suggest that perioperative administration of UTI might deserve further assessment for use in modulating acute-phase responses without adverse effects in patients who have undergone hepatic resection.

Obstructive jaundice impairs hepatic sinusoidal endothelial cell function and renders liver susceptible to hepatic ischemia/reperfusion.

BACKGROUND/AIMS: Obstructive jaundice is associated with increased surgical morbidity and mortality. While parenchymal injury has been defined in obstructive jaundice, the pathogenesis of hepatic sinusoidal endothelial cell injury in obstructive jaundice is unclear. The aims of this study were to investigate hepatic sinusoidal endothelial cell injury in obstructive jaundice by determining serum hyaluronic acid levels, purine nucleoside phosphorylase/alanine aminotransferase ratios, and hyaluronic acid elimination rate, and also to determine whether hepatic parenchymal cell injury in obstructive jaundice is induced more than in normal liver after hepatic ischemia/reperfusion. METHODS: Male Wistar rats underwent ligation and division of the common bile duct (obstructive jaundice group) or sham operation (Sham group). Serum hyaluronic acid levels and purine nucleoside phosphorylase/alanine aminotransferase ratios in both groups were examined at intervals up to 21 days after surgery. Hepatic blood flow, permeability, neutrophil accumulation, and hyaluronic acid elimination rates in both groups were measured 14 days after surgery. Changes in serum hyaluronic acid and alanine aminotransferase concentrations were determined after 15 min of hepatic ischemia followed by reperfusion. RESULTS: Serum hyaluronic acid levels remained elevated after bile duct ligation. Hepatic sinusoidal endothelial cell swelling was observed by electron microscopy, and hepatic permeability was increased 14 days after bile duct ligation in association with neutrophil accumulation. Hepatic blood flow in obstructive jaundice remained unchanged, but hyaluronic acid elimination capacity was less than that in the Sham group. After hepatic reperfusion, the disappearance rate of serum hyaluronic acid in obstructive jaundice was lower, and serum alanine aminotransferase levels were higher than those in the Sham group. CONCLUSIONS: Our findings suggest that obstructive jaundice impairs sinusoidal endothelial cells and that sinusoidal endothelial cell damage in association with sinusoidal deterioration during obstructive jaundice renders liver susceptible to ischemia/reperfusion relative to normal liver.

[Hepatectomy (parenchyma-preserving) for hilar cholangiocarcinoma].

The aim of this study was to evaluate the results of parenchyma-preserving hepatectomy as surgical treatment for hilar cholangiocarcinoma. Ninety-three resected patients with hilar cholangiocarcinoma were included in this study. The resected patients were stratified into three groups: the extended hepatectomy (EXH) group (n = 66); the parenchyma-preserving hepatectomy (PPH) group (n = 14); and the local resection (LR) group(n = 13). The EXH group underwent hepatectomy more extensive than hemihepatectomy, the PPH group underwent hepatectomy less extensive than hemihepatectomy; and the LR group underwent extrahepatic bile duct resection without hepatic resection. Surgical curability of the PPH and EXH groups was better than that of the LR group. Surgical morbidity was higher in the EXH group(48%) than in the LR group (8%) and the PPH group(14%) (p < 0.01 and p < 0.05, respectively). The survival rates after resection were significantly higher in patients who underwent hepatectomy, including PPH and EXH, than in patients who underwent LR (29% vs 8% at 5 years, respectively, p < 0.05). However, no significant difference in survival was found between the PPH and EXH groups. Univariate and multivariate analysis showed that significant prognostic factors for survival were resected margins, lymph node status, and vascular resection. In conclusion, PPH may be beneficial in highly selected patients based on cancer extent and high-risk patients with liver dysfunction and advanced age.

Beneficial effects of arterialization of the portal vein on extended hepatectomy.

BACKGROUND: Extended hepatectomy may result in postoperative liver failure. The aim of this study was to evaluate the effects of arterialization of the portal vein on oxygen supply, hepatic energy metabolism and liver regeneration after extended hepatectomy. METHODS: Portal haemodynamics were evaluated 0 or 10 days after arterialization of the portal vein in three experimental groups: 85 per cent partial hepatectomy, 85 per cent partial hepatectomy 10 days after arterialization of the portal vein and 85 per cent partial hepatectomy 10 days after ligation of the hepatic artery. Survival rates, weight of the regenerating liver, levels of adenine nucleotides and hepatic energy charge were assessed. RESULTS: Arterialization of the portal vein caused a significant increase in partial pressure of oxygen and oxygen saturation. Portal blood flow 10 days after arterialization was significantly increased. Survival rate and weight of the regenerating liver in the group with arterialization of the portal vein were significantly higher than those in the other two groups. The group with arterialization of the portal vein showed the highest levels of adenosine 5'-triphosphate. CONCLUSION: The increase in portal blood flow and oxygen supply produced by arterialization of the portal vein has beneficial effects on hepatic energy metabolism and liver regeneration, and leads to improved survival after experimental extended hepatectomy.

Plasma human hepatocyte growth factor concentrations in patients with biliary obstruction.

BACKGROUND: It has been suggested that human hepatocyte growth factor (hHGF) maintains the growth and viability of hepatocytes and biliary epithelial cells. The purpose of this study was to determine plasma hHGF concentrations in patients with obstructive jaundice and to correlate these findings with clinical outcome. METHODS: The study included 22 patients who had biliary obstruction and underwent percutaneous transhepatic biliary drainage. The plasma concentrations of hHGF, standard liver function tests, daily bile flow and the half-life of serum total bilirubin were measured following the drainage. RESULTS: Plasma hHGF concentrations were significantly higher in patients with biliary obstruction compared with a control group (P<0.01). The plasma hHGF concentrations correlated with white cell count, prothrombin time and bilirubin half-life (P<0.05), but not with the values from other liver function tests. Seven patients who died within 3 months after biliary drainage had significantly higher concentrations of plasma hHGF than the 15 patients who survived for at least 3 months (P<0.05). The patients who experienced a poor outcome also had lower bile flows and prolonged bilirubin half-lives compared with the survivors (P<0.05). The plasma hHGF concentrations decreased significantly after biliary drainage in the survivors (P<0.01), but not in the patients with a poor outcome. CONCLUSIONS: These results suggest that systemic inflammation and the hepatic dysfunction caused by obstructive jaundice cause an increase in the plasma concentrations of hHGF. In addition, the plasma concentrations of hHGF may be a predictor of poor outcome in jaundiced patients.

Unilateral hepatic artery reconstruction is unnecessary in biliary tract carcinomas involving lobar hepatic artery: implications of interlobar hepatic artery and its preservation.

BACKGROUND/AIMS: The interruption of hepatic arterial flow when performing a bilioenteric anastomosis has been reported to usually bring about serious postoperative complications, such as anastomotic leakage, hepatic abscess and infarction. We aimed to evaluate the surgical implications of the interlobar hepatic artery when patients with advanced biliary tract carcinomas undergo surgical resection with a bilioenteric anastomosis. METHODOLOGY: In 7 patients with advanced biliary tract carcinomas, the combined resection of the liver (greater than hemihepatectomy in 2 and less than hemihepatectomy in 5), extrahepatic bile duct, hepatic artery (right hepatic artery in 5, right and left hepatic artery in 1, left hepatic artery in 1), and the portal vein was performed in 4 patients. The portal vein was reconstructed in all 4 patients. The hepatic artery was reconstructed in only one patient, with combined resection of both right and left hepatic arteries, but was not reconstructed in 2 other patients, even though they underwent resection greater than hemihepatectomy. RESULTS: The interlobar hepatic artery running into the Glissonian sheath around the hepatic duct confluence could be preserved in 5 patients, as shown by angiography, but could not be preserved in 2 patients who underwent greater than hemihepatectomy. Moderate and transient ischemic liver damage occurred, but no serious postoperative complications were induced in any of the 5 patients in the unilateral hepatic artery preserved group. However, both cases without preservation of the hepatic artery encountered liver failure, liver abscess and leakage of bilioenteric anastomosis, and one patient died of multiple organ failure. CONCLUSIONS: One major lobar branch of the hepatic artery involved by cancer invasion could be safely resected without reconstruction in patients with advanced biliary tract carcinomas when the interlobar hepatic artery running into the Glissonian sheath around the hepatic duct confluence is preserved.

Parenchyma-preserving hepatectomy in the surgical treatment of hilar cholangiocarcinoma.

BACKGROUND: Although extended hepatic resection has been shown to improve prognosis by increasing the surgical curability rate in hilar cholangiocarcinoma, high surgical morbidity and mortality rates have been reported in patients with obstructive jaundice. Postoperative liver failure after hepatic resection in patients with obstructive jaundice has been shown to depend on the volume of the resected hepatic mass. The aim of this study was to evaluate the results of parenchyma-preserving hepatectomy in a surgical treatment for hilar cholangiocarcinoma. STUDY DESIGN: Ninety-three resected patients with hilar cholangiocarcinoma were included in this retrospective study. The resected patients were stratified into three groups: the extended hepatectomy (EXH) group (n = 66), the parenchyma-preserving hepatectomy (PPH) group (n = 14), and the local resection (LR) group (n = 13). The EXH group had undergone hepatectomy more extensive than hemihepatectomy, the PPH group had undergone hepatectomy less extensive than hemihepatectomy, and the LR group had undergone extrahepatic bile duct resection without hepatic resection. Surgical curability, defined by histologically confirmed negative surgical margins, surgical morbidity and mortality, and survival rates were compared among the three groups. The clinicopathologic factors were studied for prognostic value by univariate and multivariate analyses. RESULTS: Surgical curability of the PPH and EXH groups was better than that of the LR group. Fifty-four percent of patients in the LR group showed positive surgical margins at the hepatic stump of the bile duct, compared with 7% in the PPH group and 20% in the EXH groups (p < 0.01 for each comparison). Surgical morbidity was higher in the EXH group (48%) than in the LR group (8%) and the PPH group (14%) (p < 0.01 and p < 0.05, respectively). Postoperative hyperbilirubinemia occurred more frequently in the EXH group (29%) than in the LR and PPH groups (0% and 0%, respectively, p < 0.05 for each comparison). Survival rates after resection were significantly higher in patients who underwent hepatectomy, including PPH and EXH, than in patients who underwent LR, 29% versus 8% at 5 years, respectively (p < 0.05). But no significant difference in survival was found between the PPH and EXH groups. Univariate and multivariate analyses showed that significant prognostic factors for survival were resected margin, lymph nodal status, and vascular resection. CONCLUSIONS: In conclusion, PPH could obtain a curative resection and improve the outcomes for patients with hilar cholangiocarcinoma that is localized at the hepatic duct confluence who do not require vascular resection. PPH might bring about a beneficial effect in highly selected patients according to extent of cancer and high-risk patients with liver dysfunction.

Changes in hepatic venous oxygen saturation related to the extent of regeneration after partial hepatectomy in rats.

BACKGROUND: Changes in hepatic oxygen metabolism in relation to the extent of liver regeneration are expected after partial hepatectomy. There are few reports, however, about hepatic oxygen metabolism during liver regeneration. In this study, we evaluated changes in hepatic oxygen metabolism related to the regeneration rate, and the relationship between hepatic venous oxygen saturation (Shvo2) and liver regeneration after partial hepatectomy. METHODS: The work was done using 50% hepatectomized rats with continuous infusion of octreotide for inhibition of liver regeneration or with saline as control. The hepatic hemodynamics, oxygen metabolism, and Shvo2 levels as well as the regenerating liver status were evaluated for 3 days after hepatectomy. RESULTS: Administration of octreotide resulted in a significant reduction of the regenerating liver weight on days 1 and 3 after hepatectomy compared with the control group. Significantly decreased DNA synthesis and proliferating cell nuclear antigen labeling index were also found on day 1. Meanwhile, hepatic oxygen consumption (HVO2) and oxygen extraction ratio were significantly decreased in the octreotide-treated group on day 1. In contrast, the Shvo2 levels in the octreotide-treated group were significantly higher than those in the control group, and were inversely correlated with the HVO2. CONCLUSION: The remnant liver demands an increased amount of oxygen in relation to the extent of regeneration, and changes in the Shvo2 are inversely correlated with the HVo2. Therefore, monitoring the Shvo2 could be useful for estimating liver regeneration after partial hepatectomy.

Enhanced polymorphonuclear neutrophil-mediated endothelial cell injury and its relation to high surgical mortality rate in cirrhotic patients.

OBJECTIVE: A high incidence of complications has been documented in patients with cirrhosis after operations. Recently, polymorphonuclear neutrophils (PMN) have been revealed to have the capacity to injure vascular endothelium and to cause organ damage. Furthermore, the altered function of PMN has been shown in patients with cirrhosis. However, there are few reports investigating the interaction between PMN and endothelial cells and its relation to a high incidence of postoperative complications in cirrhosis. The aim of this study was to evaluate PMN-mediated endothelial cell injury in patients with cirrhosis. METHODS: Patients were divided into two groups: those who had normal liver with metastatic liver carcinoma and those who had cirrhosis with hepatocellular carcinoma. All patients in both groups underwent hepatic resection. PMN were isolated from patients before operation. Human umbilical vein endothelial cells and PMN were cocultured after addition of phorbol myristate acetate. The release of lactate dehydrogenase (LDH) and thrombomodulin in the cocultured medium and the elastase activity in PMN suspension were measured. RESULTS: The release of both LDH and thrombomodulin in the group with cirrhosis was significantly higher than in the group with normal liver. The elastase activity was similarly higher in the group with cirrhosis than in the group with normal liver. The surgical morbidity rate was remarkably higher in the group with cirrhosis (50%) than in the group with normal liver (0%). CONCLUSIONS: This study shows that PMN have an enhanced potential to cause endothelial cell injury in patients with cirrhosis. This PMN "priming" may be responsible for the occurrence of postoperative complications in patients with cirrhosis after hepatectomy.

Treatment of unresectable hepatic hilar malignancies with self-expanding metallic stents.

BACKGROUND/AIMS: This study assesses the treatment of biliary obstruction in patients with hilar malignancies by metallic stents. METHODOLOGY: Twenty-one consecutive patients with unresectable malignant biliary obstruction at the hepatic hilum (Bismuth type II, III and IV) were treated with percutaneous transhepatic placement of self-expandable metallic endoprostheses. The endoprostheses were successfully inserted in all patients. In 12 patients all segments of the liver were drained and in 9 patients partial segments of the liver were drained. RESULTS: Seventeen patients (81%) showed relief from jaundice and could be freed of external drainage tubes. Ten patients (48%) showed no recurrent symptoms due to stent obstruction until death. Overall survival was 4.86+/-4.15 (mean+/-SD) months, stent patency was 3.76+/-3.64 months and comfort index representing a ratio of well-being was 70.5+/-38.3%. There was no significant difference in survival rate, stent patency or comfort index between the groups with complete and those with partial drainage. CONCLUSIONS: Even in patients with complicated hepatic hilar biliary occlusions, internal drainage using metallic stents can relieve jaundice and leave patients free of external tubes with a comfortable quality of life.

Effective hepatic artery chemoembolization for advanced hepatocellular carcinoma with extensive tumour thrombus through the hepatic vein.

BACKGROUND AND AIMS: Advanced hepatocellular carcinoma (HCC) with extensive tumour growth through the hepatic vein still has an extremely poor prognosis, even after cancer chemotherapy and/or transarterial embolization. Although aggressive surgical treatments using extracorporeal circulation and liver transplantation have been performed by some authors, the reported results were still unsatisfactory. In this study, we report the favourable result of hepatic artery chemoembolization and subsequent surgical resection in three patients with advanced HCC with extensive tumour thrombus through the hepatic vein. METHODS AND RESULTS: Three irresectable patients with HCC with extensive tumour thrombus through the hepatic vein underwent hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam. After the reduction of tumour extent with hepatic artery chemoembolization, two of the three patients underwent surgical resection. These two patients are still alive at 59 and 21 postoperative months, respectively. In the other case, the extent of the tumour and functional reserve of the liver prevented us from performing surgical resection, but the patient is doing well 62 months after the initial treatment. CONCLUSIONS: Hepatic artery chemoembolization with aclarubicin, mitomycin C, lipiodol and/or Gelfoam might be an effective treatment for irresectable advanced HCC with extensive tumour thrombus into the inferior vena cava or the right atrium through the hepatic vein. Radical surgical resection might be applicable for selected patients without high surgical risk after reducing tumour extent by hepatic artery chemoembolization.

Does aggressive surgical resection improve the outcome in advanced gallbladder carcinoma?

BACKGROUND/AIMS: Patients with advanced gallbladder carcinoma have usually been considered nonresectable, leading to a very poor outcome. This study was aimed to evaluate the results of our aggressive surgical approaches in certain cases of advanced gallbladder carcinoma. METHODOLOGY: Ninety-one patients with advanced gallbladder carcinoma of stages pT3 and pT4 who underwent surgery at our institution were the subjects of this study. Fifty-eight of 91 patients had surgical excision; 44 by hepatic resection and 14 by hilar resection. Post-operative outcome was evaluated. Advanced gallbladder carcinomas were classified according to our previously reported classification: type I hepatic; type II biliary; type III hepatobiliary; type IV others. RESULTS: Curative resection was obtained at a more increased rate in type I tumor patients than in types II and III (91% vs. 29%, p < 0.01). The surgical mortality rate was 17%. Survival rates of resected patients were significantly higher that those of nonresected patients: 45%, 31%, 22%, 17%, 13% at 1, 2, 3, 4, 5 years vs. 9%, 9%, 0% at 1, 2, 3 years (p < 0.01). Survival rates of type I tumor patients after curative resection were remarkably higher than those of type II and III tumor patients, (69%, 64%, 56%, 48%, 39% at 1, 2, 3, 4, 5 years vs. 17%, 17%, 0% at 1, 2, 3 years). CONCLUSIONS: Aggressive surgical approaches might bring about improved prognosis in advanced gallbladder carcinoma, especially for patients with type I tumors.

Adjuvant regional chemotherapy after hepatic resection for colorectal metastases.

BACKGROUND: This study explored the possibility of achieving a better survival rate and reduced recurrence in the remaining liver in patients with colorectal hepatic metastases undergoing hepatic resection. Adjuvant postoperative regional chemotherapy was administered via the hepatic artery or the portal vein. METHODS: A retrospective study was performed on 174 patients after hepatic resection for colorectal metastases. These comprised 78 patients who had hepatic artery infusion (HAI) chemotherapy (HAI group), 30 who had portal vein infusion (PVI) chemotherapy (PVI group) and 66 who had no regional chemotherapy (resection alone group). The three groups were compared with one another in terms of complications, survival rate and patterns of recurrence. RESULTS: Severe complications did not occur at any point during adjuvant HAI or PVI chemotherapy. The 5-year disease-free survival rate of patients in the HAI, PVI and resection alone groups were 35, 13 and 9 per cent respectively, including six hospital deaths. Patients in the HAI group showed significantly improved recurrence rates in the remaining liver compared with the resection alone group (P = 0.03), and more prolonged disease-free and overall survival than those in the PVI (P = 0.01 and P = 0.02 respectively) and resection alone (P = 0.0001 and P = 0.0006 respectively) groups. CONCLUSION: This study suggests that adjuvant HAI chemotherapy after hepatic resection may have therapeutic potential for improved management of patients with colorectal metastases.

Serum interleukin-6 levels in patients with biliary obstruction.

BACKGROUND/AIMS: The clinical significance of the interleukin-6 (IL-6) response in patients with biliary obstruction was studied. METHODOLOGY: This study included 30 patients who had biliary obstruction and underwent percutaneous transhepatic biliary drainage. Cases complicated by cholangitis were excluded. The serum levels of IL-6 and standard liver function tests were examined before and after biliary drainage. RESULTS: Serum IL-6 levels were significantly higher in patients with biliary obstruction compared to control subjects (p<0.05). After drainage, serum IL-6 levels decreased significantly (p<0.01). The patients with serum IL-6 levels exceeding 10 pg/ml were characterized by lower hepaplastin values, lower serum levels of total protein and albumin, higher mean age, and more frequently positive cultures of bile compared to those with serum IL-6 levels of less than 10 pg/ml. Serum IL-6 levels were correlated negatively with hepaplastin values and serum levels of total protein and albumin (p<0.05). CONCLUSIONS: These results suggest that subclinical biliary infection, liver dysfunction and advanced age promote the IL-6 response in patients with biliary obstruction. Such a cytokine response may disturb the physiologic immune response after the ensuing major operation and may be related to some post-operative complications.