Laparoscopic repair of intestinal malrotation complicated by midgut volvulus.

Intestinal malrotation is rare in older children and adults. We performed laparoscopic repair and treatment for a 13-year-old girl diagnosed as having intestinal malrotation complicated by midgut volvulus. Under laparoscopic vision, the midgut volvulus was untwisted by grasping and pulling the intestine; Ladd's band was divided and broadened; hepatic and splenic flexure of the colon was fixed; and finally an appendectomy was performed. The patient was walking and able to resume oral intake on the first postoperative day. There was no complaint in 6 months of follow-up, and the small incisional scar satisfied the patient and her parents.

Roles of integrins and CD44 on the adhesion and migration of fetal liver cells to the fetal thymus.

Adhesion and migration of mouse fetal liver (FL) cells to the thymus were investigated using cells from green fluorescent protein transgenic (GFP+) mice. FL cells from GFP+ embryos at 12 gestational days (E12) of mice were incubated with 2'-deoxyguanosine-treated fetal thymus lobe (from E14) by thymic repopulation (hanging drop) culture methods. GFP+ cells were observed in the thymus lobe at the end of the repopulation culture period. A large part of the infiltrated cells expressed CD44 until day 2 of culture on a permeable membrane, then lost the expression. CD25 expression was observed from day 1 to day 4. Around day 8, GFP+ cells became both CD4+ and CD8+. The results support the early observation of the sequential expression of CD44, CD25, and CD4/8 during the early stages of thymocyte development. When anti-CD44 mAb was added at the beginning of the repopulation culture period, GFP+ FL cells adhered to the surface of the thymus lobe but did not migrate into the thymus. Pretreatment of the thymus with hyaluronidase or hyaluronate produced results similar to the results of anti-CD44 treatment. On the other hand, the addition of anti-integrin alpha4 mAb inhibited adhesion to the thymus, and almost no GFP+ cells were seen on the surface of the thymus lobe. The data suggest that integrin alpha4 and CD44 play different roles, i.e., integrin alpha4 is required for the adhesion of FL cells to the thymus lobe and CD44 is required for the migration of the cells into the thymus.

Green fluorescent protein-transgenic mice: immune functions and their application to studies of lymphocyte development.

Green fluorescent protein (GFP) transgenic (GFP+) mice express GFP in most tissues except erythrocytes and hair. Immune responses of GFP+ mouse and their application to studies of lymphocyte development were investigated. Flow cytometric analyses revealed that differentiation patterns of lymphocytes from GFP+ mice are equivalent to those from parental C57BL/6 mice. There was no difference in mature T-cell proliferative ability in response to allogeneic stimulator cells or anti-CD3epsilon stimulation between GFP+ and C57BL/6 mice. Furthermore, the anti-OVA antibody response of GFP+ mice was also the same as that of C57BL/6 mice. Taken together, these results show no immunological differences between GFP+ and C57BL/6 mice. Bone marrow transplantation and in vitro thymus reconstitution experiments were performed in an attempt to apply the GFP+ mice to the analysis of lymphocyte development. When bone marrow cells from GFP+ mice were transplanted. T and B lymphocytes containing GFP developed normally in scid recipients. Next we examined intrathymic T-cell development by hanging drop culture methods. GFP+ and CD4+8+ immature T-cells developed normally from bone marrow cells in the reconstituted thymus. The experimental system using hematopoietic cells from GFP+ mice is a powerful tool for visualizing lymphocyte development.

Anatomical and physiological problems of Segment IV: liver transplants using left lobes from living related donors.

We reviewed the problem of Segment IV in using left lobes from living related donors, in 18 left-lobe transplants performed on pediatric patients who ranged in age from 6.0 to 17.3 yr, and in body weight from 19.8 to 58.0 kg. The separate monitoring of oxygen saturation of hemoglobin in the liver sinusoid of segments, using a spectrophotometric technique, demonstrated a delay in re-oxygenation of Segment IV after the portal reflow, and revealed its return to comparable oxygenation with Segments II and III by the re-arterialization. Hemoglobin content, which was determined by the same technique, occasionally increased in Segment IV during the operation, implying sluggish microcirculation caused by inadequate hepatic venous drainage. These characteristic profiles on tissue oxygenation and hemodynamics in Segment IV should be considered when using left lobes as living related liver grafts.

Experiences of 120 microsurgical reconstructions of hepatic artery in living related liver transplantation.

BACKGROUND: We reviewed 120 microsurgical reconstructions of a hepatic artery in living related liver transplantation and discussed the problems encountered. METHODS: From January 1991 to July 1994 we performed a series of 105 living related liver transplantations on children with end-stage liver disease. Arterial reconstruction was performed under the optical field of a continuous zoom magnification of approximately 10 times with an operating microscope. RESULTS: Twenty-six percent of the graft arteries were less than 2 mm in diameter. The time required for an arterial reconstruction was 49.5 +/- 1.8 minutes. In 15 of the 31 cases in which there were two graft arteries, two arterial reconstructions were required. The caliber differences between the graft artery and the recipient artery in 30 instances was dealt with by cutting an undersized artery obliquely (17 instances), by fish-mouth method (10 instances), by end-to-side anastomosis (1 instance), or by funnelization method (2 instances). In one case we performed an intimal dissection of a recipient hepatic artery and substituted a splenic artery. Consequently, hepatic arterial thrombosis occurred in only two cases (1.7%). CONCLUSIONS: Microsurgical technique has overcome the high risk of hepatic arterial thrombosis in cases of fine graft arteries, enabled the reconstruction of arteries with caliber difference, and decreased arterial complications with its delicate manipulation.

Changes in lymphocyte beta 2-adrenoceptors after hepatic resection.

Hepatic resection promotes such a high degree of surgical stress that it induces deterioration of various vital functions, which may involve the breakdown of signal transduction systems. To investigate the influence of surgical stress on signal transduction, we studied ligand-receptor specific binding activity after hepatic resection, focusing on lymphocyte beta 2-adrenoceptors. The maximum binding capacity (Bmax) and the dissociation constant (KD) were determined by radioligand binding assay using (-)3H-CGP12177 as a ligand. In the hepatectomy group, Bmax significantly decreased from 1380 +/- 109 to 799 +/- 49 receptors/cell on postoperative day (POD) 3 and to 802 +/- 93 receptors/cell on POD 7 (P < 0.05). In the control group, however, it did not significantly change after the operation. No significant changes in KD were found in either of these groups. The Bmax alteration was not due to the redistribution of lymphocyte subsets or receptor down regulation, but to the decrease in the Bmax of the individual subset. The hepatectomy group was divided into two groups according to the postoperative arterial ketone body ratio (AKBR): Group A, AKBR maintained at 0.7 or more; and Group B, AKBR decreased to below 0.7. The Bmax decrease, a percentage of the preoperative value, of Group B was significantly smaller than that of Group A (48.4 +/- 3.9 and 72.3 +/- 7.3%, respectively, P < 0.05). These results suggest that intense surgical stress, produced by hepatic resection, may influence even ligand-receptor binding parameters, and the decrease in AKBR can indicate the magnitude of surgical stress.

Effect of growth hormone on hepatic energy metabolism in normal rabbit liver.

Growth hormone (GH), which is well known as an anabolic agent in systemic protein metabolism but has catabolic effects on the carbohydrate metabolism in the liver, was administered to normal rabbit to investigate its effects on the hepatic energy metabolism. The changes in arterial ketone body ratio (AKBR: acetoacetate/3-hydroxybutyrate), which reflects the hepatic mitochondrial redox state ([NAD+]/[NADH]), after GH injection was studied as an indicator of the hepatic energy metabolism. GH was administered to normal rabbit at the doses of 50 micrograms/kg (GH-50 group), 100 micrograms/kg (GH-100 group) and 200 micrograms/kg (GH-200 group) by intravenous bolus injection. In the GH-50, GH-100 and GH-200 groups, AKBR decreased significantly from 1.40 +/- 0.09 to 0.94 +/- 0.05, from 1.19 +/- 0.11 to 0.83 +/- 0.14, and from 1.19 +/- 0.08 to 0.71 +/- 0.15 at 90 min, respectively. The energy charge of the liver decreased significantly 90 min after 200 micrograms/kg GH injection from 0.872 +/- 0.003 to 0.836 +/- 0.012 (p < 0.05). These results suggest that GH is associated with the deterioration of the hepatic energy metabolism, and that the administration of GH should be carefully weighed up in cases of damaged liver.

Hemodynamics and hepatic energy metabolism in canine model of acute hepatic venous occlusion with mesocaval shunt.

The relationship between portal hemodynamics and the energy metabolism of the liver with acute hepatic venous occlusion (HVO) was investigated by assessing the changes in the hepatic blood flow, arterial blood ketone body ratio (AKBR) and adenylate energy charge potential (ECP) of the liver tissue in canine model. Acute HVO was induced by the ligation of both the supra- and infrahepatic inferior vena cava (IVC) over the protruding ends of a heparin-coated polyethylene cannula inserted into the IVC. All dogs with only HVO (n = 5) died within 30 min. HVO dogs with additional mesocaval (MC) shunt (n = 10) survived longer than 7 days, during which time their AKBR were maintained in the normal range (over 1.0). ECP was also maintained above the normal level (over 0.850) during the 28-day period. Along with increasing portal pressure caused by the narrowing of the shunt anastomosis, the hepatic blood flow decrease gradually, resulting in a sudden decrease in AKBR and ECP when the portal pressure increased over 11 mm Hg. It is suggested that the normalization of portal pressure is one of the most important factors for maintaining the hepatic energy metabolism and that MC shunt is an effective therapy for maintaining the function of the liver with HVO, as long as portal pressure can be kept within normal range.

Effect of prostaglandin E1 on preservation injury of canine liver grafts preserved in UW solution.

This study investigated whether prostaglandin E1 (PGE1) could reduce hepatic injury to the liver graft caused by harvesting and 24-h preservation in University of Wisconsin (UW) solution in a canine model. The PGE1-treated group was intravenously administered 0.5 microgram/kg per minute of PGE1 for 30 min before harvesting, as well as a concentration of 1 mg/l PGE1 in the washout and UW solutions. In both the PGE1-treated and the control group, all recipients survived for 1 week or more after transplantation. Arterial ketone body ratio (AKBR) remained over 1.0 in the early postoperative period. The PGE1 group showed significant reductions in guanase, GOT, and LDH during the early postoperative period compared to the untreated control group. Histological examination disclosed partial mitochondrial swelling, hepatocyte vacuolation, and necrosis in the control group, while such abnormalities were rarely seen in the PGE1 group. These results suggest that PGE1 can effectively reduce hepatic injury to liver grafts preserved in UW solution prior to transplantation.

Relief of hepatic vein stenosis by balloon angioplasty after living-related donor liver transplantation.

We have experienced 5 hepatic vein stenoses in 3 children (8 to 23 months old) after living-related liver transplantation (total 48 liver transplants for 48 children between June 1990 and November 1992). The initial symptoms of hepatic vein stenosis were ascites and/or edema. The blood flow of hepatic vessels was monitored by duplex sonography. The mean velocity of the hepatic vein and the portal vein was decreased and flow wave pattern of the stenotic hepatic vein was flat. The patients were treated by percutaneous transhepatic balloon angioplasty. After a successful angioplasty, the mean velocity of the hepatic vein and portal vein increased and pulsatile waves returned to the hepatic vein. Arterial ketone body ratio (acetoacetate/3-hydroxybutylate) increased, promptly followed by recovery of other liver function tests. In 1 patient, this complication occurred three times with intervals of 7 months and 3 months between episodes of hepatic vein stenosis. In conclusion, hepatic vein flow should be monitored routinely with duplex sonography after living-related donor liver transplantation. Percutaneous transhepatic balloon angioplasty is a primary treatment for the stenosis.

Protective effect of platelet-activating factor antagonist on hepatic energy metabolism following transient hepatic inflow occlusion in rabbits.

To investigate whether or not platelet-activating factor (PAF) is a mediator of the liver injury resulting from transient hepatic inflow occlusion (Pringle's maneuver), the effect of pretreatment with a potent PAF antagonist (CV6209) on hepatic energy metabolism was evaluated following 30 min of inflow occlusion in rabbits. At 60 min after declamping, the arterial ketone body ratio (AKBR; acetoacetate/3-hydroxybutyrate), reflecting hepatic mitochondrial redox state (NAD+/NADH), increased to 1.10 +/- 0.05 (mean +/- SEM) in the CV6209 (5 mg/kg)-pretreated group (group 1, n = 5) compared with 0.72 +/- 0.06 (P less than 0.01) in the untreated group (group 2, n = 5). Hepatic energy charge at 60 min after declamping was significantly higher in group 1 than in group 2 (0.871 +/- 0.010 vs. 0.800 +/- 0.023; P less than 0.05). Pretreatment with CV6209 had no significant influence on these parameters in sham-operated animals. The present study demonstrates that pretreatment with CV6209 has a protective effect against the impairment of hepatic energy metabolism following transient hepatic inflow occlusion.

The introduction of microvascular surgery to hepatic artery reconstruction in living-donor liver transplantation--its surgical advantages compared with conventional procedures.

Microvascular surgery for the reconstruction of the graft artery has been used since the 8th case in our series of 14 liver transplantations using living-related donors, and the clinical results have been compared between the first seven cases (the Loupe group) and the last seven cases (the Micro group). Seven arteries in 7 grafts were reconstructed with the use of loupe magnification in the Loupe group, while 8 arteries in 7 grafts were anastomosed with microscopic techniques in the Micro group. Statistically, there was no difference between the two groups in general background, including age, body weight and primary disease of the recipient, and in medical and surgical factors possibly relating to postoperative thrombosis of the hepatic artery. In two cases in the Loupe group, one or two additional reconstructions were necessary to obtain sufficient blood flow, while 8 arteries were anastomosed in the Micro group without any arterial complication in the postoperative period. There was no difference in time required for completing the arterial reconstruction (45.1 +/- 18.1 min in the Loupe versus 44.4 +/- 6.9 min in the Micro [mean +/- SEM]). Postoperative ultrasonic Doppler duplex study demonstrated a temporary decrease in the arterial flow in 2 cases of the Loupe group, and partial thrombosis of the artery was suspected. Additionally there were two episodes of hepatic artery thrombosis in 1 case of the Loupe group, in which emergent revision for thrombectomy and reanastomosis was performed at the first episode. This illustrated the higher incidence of arterial complications in the Loupe group compared with the Micro group (4 episodes/7 arteries in the Loupe versus 0/8 arteries in the Micro, P less than 0.05). In the present series there were no graft failures or arterial complications in the three deaths in the series. The clinical improvements achieved by microvascular surgery in living-donor liver transplantation suggest an alternative technical strategy for dealing with problematic arterial reconstruction in adult liver transplantation.

[A case of breast cancer with pleural metastasis responding to administration of intrapleural adriamycin and systemic chemotherapy with FEMP].

A 51-year-old woman with breast cancer metastatic to the pleura was treated with intrapleural instillation of adriamycin after thoracentesis, and systemic administration of FEMP, with complete response for more than 11 months. She underwent radical mastectomy and bilateral oophorectomy for advanced breast cancer, and 18 months later presented radiological evidence of pleural fluid contralateral to the affected breast. Initially, thoracentesis for symptomatic relief was done with a positive cytology in the pleural effusion. Intrapleural instillation of adriamycin was followed by partial resolution, and administration of FEMP achieved complete disappearance of both pleural metastasis and pleural effusion.