Histology of metastatic colorectal cancer in a lymph node.

BACKGROUND: A primary colorectal cancer (CRC) tumor can contain heterogeneous cancer cells. As clones of cells with different properties metastasize to lymph nodes (LNs), they could show different morphologies. Cancer histologies in LNs of CRC remains to be described. METHODS: Our study enrolled 318 consecutive patients with CRC who underwent primary tumor resection with lymph node dissection between January 2011 and June 2016. 119 (37.4%) patients who had metastatic LNs (mLNs) were finally included in this study. Cancer histologies in LNs were classified and compared with pathologically diagnosed differentiation in the primary lesion. The association between histologies in lymph node metastasis (LNM) and prognosis in patients with CRC was investigated. RESULTS: The histologies of the cancer cells in the mLNs were classified into four types: tubular, cribriform, poorly differentiated, and mucinous. Same degree of pathologically diagnosed differentiation in the primary tumor produced various histological types in LNM. In Kaplan-Meier analysis, prognosis was worse in CRC patients with moderately differentiated adenocarcinoma who had at least some mLN also showing cribriform carcinoma than for those whose mLNs all showed tubular carcinoma. CONCLUSIONS: Histology in LNM from CRC might indicate the heterogeneity and malignant phenotype of the disease.

Triple positive tumor markers for hepatocellular carcinoma are useful predictors of poor survival.

OBJECTIVE: To determine the importance of the expression pattern of multiple tumor markers for hepatocellular carcinoma (HCC) with regard to the tumor malignancy and patient survival. BACKGROUND: Several studies have indicated that HCC tumor markers, including alpha-fetoprotein (AFP), Lens culinaris agglutinin-reactive fraction of AFP and des-γ-carboxy prothrombin were predictors of HCC malignancy. However, few reports have shown the relevance of the expression pattern of these 3 tumor markers with regard to patient prognosis. We herein reported the influence of the expression pattern of these 3 tumor markers on HCC malignancy and patient prognosis. METHODS: This retrospective study analyzed 185 patients who underwent hepatectomy for HCC between January 1999 and May 2009. The relationships between clinical parameters and these 3 tumor markers were analyzed. Cox proportional hazards regression analyses were performed to estimate risk factors for recurrence and survival. Furthermore, the relationships between pathological parameters and the expression patterns of the 3 tumor markers were analyzed. RESULTS: From clinical parameters, expression patterns of 3 tumor markers were related to maximum tumor size and macrovascular invasion in image findings. Multivariate analyses revealed independent risk factors for recurrence or survival to be the Child-Pugh score, the presence of multiple tumors, and triple positive tumor marker expression. From pathological findings, microvascular invasion and an Edmondson-Steiner classification of III or IV were related to the expression patterns of the 3 tumor markers. CONCLUSIONS: Triple positive tumor markers for HCC showed poor prognosis and invasive characteristics in pathological findings. Examination of these markers would be useful for predicting the degree of HCC malignancy.

Adjuvant chemolipiodolization reduces early recurrence derived from intrahepatic metastasis of hepatocellular carcinoma after hepatectomy.

BACKGROUND: The recurrence of hepatocellular carcinoma is still high even after surgery. Two general recurrence patterns occur: intrahepatic metastasis (IM) and multicentric carcinogenesis (MC). The aim of this study was to investigate the effectiveness of adjuvant chemolipiodolization for reducing IM or MC recurrences after surgery. METHODS: A retrospective case-control study was carried out. From April 2005, adjuvant chemolipiodolization was performed in 63 initial hepatocellular carcinoma patients 3 months after surgery. Sixty-four patients who underwent surgery between April 2001 and March 2005 were analyzed as the control group. Recurrence-free and overall survival as well as prognostic factors were analyzed univariately and multivariately. RESULTS: The 2-year recurrence-free survival was 57% in the chemolipiodolization group and 37% in the control group (P = 0.02). However, there was no significant difference at 5 years after surgery (P = 0.09). The 5-year overall survival rates in the chemolipiodolization and the control groups were 82.4 and 55.7%, respectively (P = 0.04). Cox proportional multivariate analysis revealed that adjuvant chemolipiodolization was an independent favorable prognostic factor for 2-year recurrence-free survival, and the odds ratio [95% confidential interval] was 0.55 [0.34-0.90] (P = 0.02). However, adjuvant chemolipiodolization was not an independent favorable prognostic factor for 5-year overall survival. CONCLUSIONS: Adjuvant chemolipiodolization can reduce the risk of early recurrences, which would be mainly IM derived. However, chemolipiodolization did not reduce late phase recurrences after surgery, which would be mainly MC derived. To prevent late phase recurrences, another novel strategy would be needed.

Combined intraoperative use of contrast-enhanced ultrasonography imaging using a sonazoid and fluorescence navigation system with indocyanine green during anatomical hepatectomy.

PURPOSE: The clear demarcation line is ideal for real-time surgical navigation imaging during hepatectomy. METHODS: The study population was comprised of 22 patients with moderate liver cirrhosis scheduled to undergo an anatomical liver resection for the treatment of hepatocellular carcinoma. This study set out to assess the clinical value of the concomitant intra-operative use of contrast-enhanced intra-operative ultrasound using Sonazoid™, and a fluorescence navigation system (PDE) with ICG, as a novel tool for patients undergoing an anatomical liver resection. RESULTS: Following portal pedicle ligation for anatomical resection, 2 min after injection of ICG, the segments to be resected were detected as a negative-brightness area using PDE fluorescence. Sonazoid™ administration provides a parenchymal transectional line, as the margin of a loss of blood flow shows a hypo-enhanced image, and the resectional line of the parenchyma can be confirmed by CE-IOUS. Although the demarcation line of the liver surface after the portal pedicle ligation was apparent in 17 patients, the resection line using PDE was clearly detected in all 22 patients (p < 0.018). CONCLUSIONS: The combined use of these methods is therefore considered to be useful and safe for surgeons, as an additional tool for performing a liver resection.

[Bacteria isolated from surgical infections and its susceptibilities to antimicrobial agents--special references to bacteria isolated between April 2009 and March 2010].

Bacteria isolated from surgical infections during the period from April 2009 to March 2010 were investigated in a multicenter study in Japan, and the following results were obtained. In this series, 671 strains including 16 strains of Candida spp. were isolated from 174 (79.1%) of 220 patients with surgical infections. Four hundred and eleven strains were isolated from primary infections, and 244 strains were isolated from surgical site infection. From primary infections, anaerobic Gram-negative bacteria were predominant, followed by aerobic Gram-negative bacteria, while from surgical site infection aerobic Gram-positive bacteria were predominant, followed by anaerobic Gram-negative bacteria. Among aerobic Gram-positive bacteria, the isolation rate of Enterococcus spp. was highest, followed by Streptococcus spp., and Staphylococcus spp. in this order, from primary infections, while Enterococcus spp. was highest, followed by Staphylococcus spp. from surgical site infection. Among aerobic Gram-negative bacteria, Escherichia coli was the most predominantly isolated from primary infections, followed by Klebsiella pneumoniae, Enterobacter cloacae and Pseudomonas aeruginosa, in this order, and from surgical site infection, E. coli was most predominantly isolated, followed by P. aeruginosa and E. cloacae. Among anaerobic Gram-positive bacteria, the isolation rate of Eggerthella lenta was the highest from primary infections, followed by Parvimonas micra, Streptococcus constellatus and Finegoldia magna, and from surgical site infection, E. lenta was most predominantly isolated. Among anaerobic Gram-negative bacteria, the isolation rate of Bilophila wadsworthia was the highest from primary infections, followed by Bacteroides fragilis, Bacteroides ovatus and Bacteroides thetaiotaomicron, and from surgical site infection, B. fragilis was most predominantly isolated, followed by B. ovatus, B. wadsworthia and B. thetaiotaomicron, in this order. In this series, we noticed no vancomycin-resistant Gram-positive cocci, nor multidrug-resistant P. aeruginosa. We should carefully follow up B. wadsworthia which was resistant to various antibiotics, and also Bacteroides spp. which was resistant to many beta-lactam antibiotics.

Combined use of contrast-enhanced intraoperative ultrasonography and a fluorescence navigation system for identifying hepatic metastases.

BACKGROUND: The purpose of this study was to assess the concomitant use of contrast-enhanced intraoperative ultrasound (CE-IOUS) using the new microbubble agent Sonazoid, and to assess the fluorescence navigation system (Photo Dynamic Eye, or PDE) using indocyanine green (ICG) as a novel tool for identifying colorectal metastatic lesions compared with preoperative contrast-enhanced multiple row-detected computed tomography (MDCT) and gadoxetic acid-enhanced MRI. METHODS: Thirty-two patients who underwent a liver resection for colorectal metastatic carcinoma from 2008 to 2009 were included in the present study. ICG was intravenously injected within 2 weeks of the operation. The liver was inspected with CE-IOUS using Sonazoid and PDE for visualizing small metastatic lesions. A lesion analysis was performed with the postoperative histopathological examination of the resected tissues. The clinical values of CE-IOUS and PDE to confirm the malignant lesion diagnoses were statistically evaluated. RESULTS: A total of 56 lesions were identified based on the histopathological findings of the biopsies and resected tissues; of these, 52 were confirmed to be metastases, whereas 4 were benign tumors. The numbers of identified metastases by MDCT/MRI and CE-IOUS/PDE were 46 and 51, respectively. The use of CE-IOUS and PDE improved the diagnostic sensitivity compared with the use of MDCT and EOB-MRI (98.1 vs. 88.5%, respectively; P = 0.050). CONCLUSIONS: The present results suggested that the concomitant use of CE-IOUS with the Sonazoid and PDE system may be a useful and safe method, in addition to CT or MRI.

Xanthogranulomatous cholecystitis: the use of preoperative CT findings to differentiate it from gallbladder carcinoma.

BACKGROUND AND AIM: A retrospective analysis was performed on 32 patients with histologically confirmed xanthogranulomatous cholecystitis (XGC) and 21 patients with gallbladder carcinoma who underwent surgical treatment between 1998 and 2007. METHODS: All patients underwent preoperative CT scanning. The CT features analyzed were: the presence of intramural hypoattenuated nodules or bands, mucosal line, the patterns of wall thickening and enhancement, and the presence of stones in the gallbladder. The variables of the CT findings with XGC were analyzed using multivariate logistic regression analysis. RESULTS: Intramural hypoattenuated nodules were observed in 21 patients (65%) with XGC, but in only six patients (29%) with gallbladder carcinoma (P < 0.01). The mucosal line was observed in 27 patients (84%) with XGC and in only four patients (19%) with gallbladder carcinoma (P < 0.0001). Gallstones were noted in 24 patients (75%) with XGC and five patients (24%) with gallbladder carcinoma (P < 0.001). There was no significant difference in the pattern of gallbladder wall thickening (diffuse or focal) and the presence of changes outside the gallbladder. Multivariate logistic regression analysis revealed from the CT features that the enhanced continuous mucosal line (P = 0.0013) and the presence of gallstones (P = 0.0072) were independently correlated with XGC. CONCLUSION: CT features of the enhanced continuous mucosal line in a thickened gallbladder wall, together with gallstones in a patient with chronic gallbladder disease, are highly suggestive of XGC. Accurate diagnosis of XGC may therefore indicate the need to select a less aggressive surgical approach.

A new prediction model of postoperative complications after major hepatectomy for hepatocellular carcinoma.

BACKGROUND/AIMS: Serum hyaluronic acid (HA) concentrations reflect the degree of hepatic dysfunction and may have potential for predicting postoperative complications in a major hepatectomy for hepatocellular carcinoma (HCC). METHODS: Serum HA concentrations and other conventional liver function tests were measured prior to major hepatectomies in 52 patients. Independent predictors for postoperative complications were analyzed and the discriminant equation was established and validated. RESULTS: Postoperative complications occurred in 17 patients. Serum HA concentrations and the estimated remnant liver volume ratio (remnant Vol%) were recognized as independent predictors for postoperative complications (OR 1.03, 0.85; CI 95% 1.01-1.06, 0.76-0.95; p = 0.006, 0.006; respectively) and produced the discriminant equation: logit = 4.15 + 0.03 x (HA) -0.16 x (remnant Vol%). The value of the area under the curve of a receiver operating characteristic analysis was 0.92. If the cut-off of the logit value was set to 0, then the predictive accuracy was 0.88. The validation accuracy performed by a leave-one-out cross-validation method was 0.83. CONCLUSIONS: The constructed discriminant equation model consisting of the preoperative serum HA concentrations and estimated remnant Vol% could be useful for predicting postoperative complications in a major hepatectomy for HCC.

Half clamping of the infrahepatic inferior vena cava reduces bleeding during a hepatectomy by decreasing the central venous pressure.

BACKGROUND AND AIMS: Bleeding from the hepatic vein is closely related to central venous pressure (CVP). To evaluate the effect of low central venous pressure during a hepatectomy, the infrahepatic inferior vena cava (IVC) was half clamped. PATIENTS AND METHODS: Between 2006 and 2007, 20 patients undergoing major hepatectomy with the IVC half clamping (half-clamping group) were compared with 58 patients undergoing hepatectomy without IVC half clamping between 2003 and 2005 (control group). The types of liver resection, amount of blood loss during the hepatectomy, volume of blood transfusion, length of hospital stay, and complications were compared between the two groups. RESULTS: In the half-clamping group, blood loss was decreased in comparison to the control group (p = 0.041) and the suprahepatic CVP was low (2.4 +/- 1.8 mmHg; p = 0.0002). The diameter at the root of the right hepatic vein was reduced in comparison to before clamping (5.8 +/- 1.6 mm; p < 0.001). There were no complications of half clamping on any hemodynamic and blood electrolytic parameters. CONCLUSION: Using the half clamping technique of the IVC, intra-operative CVP was maintained below 3 mmHg without any side effects, and the low CVP significantly reduced the bleeding from hepatic veins during a major hepatectomy.

Prognostic impact of treatment modalities on patients with single nodular recurrence of hepatocellular carcinoma.

PURPOSE: To evaluate the prognostic impact of various therapeutic modalities, such as repeat hepatectomy, ablation therapy, and transcatheter arterial chemoembolization (TACE) therapy, used to treat single nodular recurrent hepatocellular carcinoma (HCC). METHODS: Thirty-two patients with single nodular intrahepatic recurrence after curative primary resection of HCC were enrolled in this study. The prognostic factors after recurrence were established using 13 clinicopathologic variables, including the therapeutic modalities; namely, repeat hepatectomy, ablation therapy, or TACE therapy. RESULTS: Of the 32 patients, 9 underwent repeat hepatectomy, 10 underwent ablation therapy, and 13 underwent TACE therapy. The therapeutic modality was the only prognostic factor. In comparison with TACE therapy, the relative risks associated with ablation therapy and repeat hepatectomy were 0.19 and 0.29, respectively. The 5-year survival rates after single nodular recurrence were 57% in the ablation therapy group, 29% in the repeat hepatectomy group, and 0% in the TACE therapy group. CONCLUSIONS: Repeat hepatectomy and ablation therapy are more effective than TACE therapy for improving the prognosis of patients with single nodular intrahepatic recurrent HCC.

Adenoviral vector expressing hepatocyte growth factor promotes liver regeneration by preoperative injection: the advantages of performing selective injection to the remnant lobe.

BACKGROUND: In a cirrhotic liver, the regenerative ability is impaired and liver failure may occur after a hepatectomy. Hepatocyte growth factor (HGF) stimulates liver regeneration and adenoviral vector expressing hepatocyte growth factor (AdHGF) allows hepatocyte growth factor (HGF) to be persistently expressed. The aim of this study is to evaluate the benefits of the selective and preoperative injection of AdHGF to the remnant lobes to regenerate the liver. METHODS: A 70% partial hepatectomy was performed in dimethylnitrosamine-induced cirrhotic rats with a preoperative injection of AdHGF, adenoviral vector carrying beta-galactosidase (AdLacZ), or phosphate-buffered saline (PBS). The morphologic, histologic, and biochemical changes in the remnant liver and survival rates were then assessed. RESULTS: Portal injection with clamping the portal branches of the resected lobes for 5 min made it possible to effectively transduce the adenoviral vector into the remnant lobes. On day 7 after hepatectomy, the survival rates were 87% in the AdHGF group, 53% in the AdLacZ group, and 40% in the PBS group (P < .05). The ratio of the remnant liver weight/body weight (%) was 2.0 +/- 0.1 in the AdHGF group, 1.5 +/- 0.3 in the AdLacZ group, and 1.6 +/- 0.04 in the PBS group (P < .01). The 5-bromo-2'-deoxyuridine labeling index significantly increased in the AdHGF group on day 1, and the fibrous status significantly decreased in the AdHGF group on day 7 after hepatectomy. CONCLUSIONS: Preoperatively, the selective injection of AdHGF into the remnant lobes may be an effective treatment prior to a major hepatectomy in a cirrhotic liver.

Reducing residual and recurrent stones by hepatectomy for hepatolithiasis.

The long-term outcomes of 97 consecutive patients with hepatolithiasis, who underwent treatment from January 1971 to June 2006, were analyzed. The short-term outcomes included the rate of residual stones and complications after treatment, whereas the long-term results included the stone recurrence rate. In 22 of the 97 (22.7%) patients, residual stones were found after treatment for hepatolithiasis. The incidence of residual stones was 0% in hepatectomy patients, 48.6% in cholangioenterostomy patients (p < 0.001, compared with hepatectomy), 25.0% in T-tube drainage patients (p = 0.015, compared with hepatectomy), and 10.0% in percutaneous transhepatic cholangioscopic lithotripsy (PTCSL) patients. In 15 of the 66 (22.7%) patients who were treated for hepatolithiasis, recurrent stones were found after intervals of 5 to 24 years. The incidence of recurrent stones was 13.9% in hepatectomy patients, 28.5% in cholangioenterostomy patients, 25.0% in T-tube drainage patients, and 50.0% in PTCSL patients (p = 0.021, compared with hepatectomy). Hepatectomy appears to be the most effective treatment for selected patients with isolated left hepatolithiasis (L). In PTCSL procedures, favorable results have been obtained when the stones were completely cleared; however, the incidence of recurrent stones is high in patients after PTCSL.

Prevention of postoperative infections by administration of antimicrobial agents immediately before surgery for patients with gastrointestinal cancers.

BACKGROUND/AIMS: This study was conducted to judge the effect of intravenous administration of antimicrobial agents immediately before surgery for patients with gastrointestinal cancers to prevent postoperative surgical site infections (SSIs) and remote site infections. METHODOLOGY: A total of 3437 patients with gastrointestinal cancers underwent standby operations in Wakayama Medical University Hospital between 1987 and 2002. Of these, 1483 were treated between 1987 and 1995, and intravenous antimicrobial agents were used only postoperatively for 2 to 5 days (no AMP group). In addition to the postoperative administration, antimicrobial agents were injected immediately before surgery in 1954 patients (AMP group). If the operation continues more than 3 hours, antimicrobial agents were injected every 3 hours during operation. A comparison was made between the no AMP group and AMP group concerning the bacteria detected and the incidence of SSIs and remote site infections. RESULTS: The incidence of superficial or deep incisional SSI after surgery was higher in esophageal cancer (17.2%) throughout the whole period than in gastric cancer (4.2%), colon cancer (5.2%) and hepatic/biliary/pancreatic cancers (4.9%) (p < 0.00001). On the other hand, the incidence of space/organ SSI after surgery was higher in hepatic/biliary/pancreatic cancers (14.7%) than esophageal cancer (8.4%; p = 0.02), gastric cancer (7.9%), and colon cancer (8.1%; p < 0.00001). The overall incidence of superficial or deep incisional SSI after surgery for gastrointestinal cancers was 7.2% in the no AMP group, and 4.1% in the AMP group (p = 0.00006). However, in the overall incidence of space/organ SSI, no significant difference was observed between the no AMP group (10.3%) and the AMP group (8.8%). In addition, the incidence of remote site infections also showed no significant difference between the two groups. Regarding bacterial isolates detected after surgery, the prevalence of methicillin-resistant Staphylococcus aureus (MRSA) decreased from 10.8% to 6.2% among the bacterial strains detected (p = 0.00009), and Pseudomonas sp. also decreased from 13.5% to 10.2% (p = 0.002), but Enterococcus sp. increased from 12.1% to 20.4% (p < 0.00001). CONCLUSIONS: Preoperative AMP was useful to suppress postoperative superficial or deep incisional SSI, but was unlikely to suppress organ/space SSI or remote site infections. In addition, due to preoperative AMP, MRSA and Pseudomonas sp., which showed SSIs, were decreased in detection rates, whereas the detection rate of Enterococcus sp., which is resistant to cephems, was increased.

Combination gene therapy of HGF and truncated type II TGF-beta receptor for rat liver cirrhosis after partial hepatectomy.

BACKGROUND: In a cirrhotic liver, the regenerative ability and specific functions are impaired; a hepatic resection increases the possibility of postoperative liver failure. Hepatocyte growth factor (HGF) stimulates liver regeneration, accelerates restoration of hepatic function, and improves fibrosis. A truncated type II transforming growth factor-beta receptor (TbetaTR), which specifically inhibits TGF-beta signaling as a dominant-negative receptor, appears to prevent the progression of liver fibrosis. We demonstrated the therapeutic efficacy of adenovirus-mediated HGF and TbetaTR gene transduction after partial hepatectomy for liver cirrhosis. METHODS: Rats were treated with dimethylnitrosamine for 3 weeks, and they all had severe cirrhosis. After partial hepatectomy (10%), we injected adenovirus expressing bacterial beta-galactosidase (AdLacZ), adenovirus expressing a truncated type II TGF-beta receptor (AdTbetaTR), adenovirus expressing hepatocyte growth factor (AdHGF), or AdTbetaTR + AdHGF into the portal vein, which was followed by an additional 2-week dimethylnitrosamine treatment. RESULTS: On histologic examination, fibrotic tissue had decreased in the livers of the AdTbetaTR + AdHGF-treated rats compared with rats that were treated by AdLacZ, AdTbetaTR alone, and AdHGF alone. Liver function, which included serum levels of alanine aminotransferase, improved significantly in AdTbetaTR + AdHGF-treated rats compared with all other groups. The number of hepatocytes that were positive for proliferating-cell nuclear antigen was greater (P < .05) in AdHGF alone and AdTbetaTR + AdHGF-treated rat livers than in AdLacZ- and AdTbetaTR-treated rats. All AdTbetaTR + AdHGF-treated rats survived >60 days, and AdTbetaTR + AdHGF treatment markedly improved the survival rate after a partial hepatectomy. CONCLUSION: Our results suggest that the combination of HGF and TbetaTR gene therapy may increase the possibility of hepatectomy in a cirrhotic liver by improving fibrosis, hepatic function, and hepatocyte regeneration.

Recurrence of primary hepatocellular carcinoma after hepatectomy--differences related to underlying hepatitis virus species.

BACKGROUND/AIMS: Studies on post-hepatectomy prognoses by infecting viral species have only been rarely reported. METHODOLOGY: The patients who had undergone hepatectomy for primary hepatocellular carcinoma (HCC) over the past 10 years at our hospital were divided into three groups based on their underlying causal diseases: hepatitis B (B type), hepatitis C (C type), and non-viral hepatitis including alcoholic hepatitis, and their backgrounds and long-term results after hepatectomy were comparatively investigated. RESULTS: As for tumor factors, the tumor diameter was 3.7+/-2.1 cm in C type patients, which was significantly smaller than the 5.2+/-3.3 cm diameter in B type patients (p=0.01) and 7.9+/-5.6 cm in non-viral patients (p=0.001). However, the frequencies of intrahepatic metastasis, portal vein infiltration, capsule formation and capsule infiltration did not differ significantly among the three groups. Although there was no significant difference observed among the three groups for the recurrence-free survival time, HCC had recurred at as early a stage as within 1 postoperative year in 50% of non-viral patients. CONCLUSIONS: The size of a tumor upon hepatectomy and the presence or absence of intrahepatic metastasis were found to be significant factors contributing to the postoperative recurrence of HCC. It is possible that the recurrence-free postoperative survival time may be prolonged by earlier detection of HCC, particularly for the B type and the non-viral type in which the tumor size was already large at the time of surgery.

Risk factors for postoperative infectious complications after hepatectomy.

BACKGROUND/PURPOSE: This study aimed to clarify the incidence of surgical site infections (SSIs) after hepatectomy. METHODS: The database records of three hundred and eight patients who underwent elective surgical treatment for hepatolithiasis, hepatocellular carcinoma (HCC), and metastatic carcinoma were retrospectively analyzed to determine the occurrence of postoperative infectious complications. The incidences of SSIs, classified as superficial or deep incisional SSIs and organ or space SSIs, and all other infectious complications within 30 days after hepatectomy were evaluated. RESULTS: The incidences of SSIs after a hepatectomy for hepatolithiasis (23.8%) were higher than those after a hepatectomy for HCC (11.3%) (p = 0.034) and after a hepatectomy for metastatic carcinoma (2.7%) (p < 0.001), and the incidence of SSIs after a hepatectomy for HCC was higher than that after a hepatectomy for metastatic carcinoma (p = 0.028). However, there was no significant difference in the incidence of remote site infections between the three groups. The incidence of superficial or deep incisional SSIs after a hepatectomy for hepatolithiasis (11.9%) was higher than that after a hepatectomy for metastatic carcinoma (1.4%) (p < 0.001) and the incidence of superficial or deep incisional SSIs after a hepatectomy for HCC (7.8%) was higher than that after a hepatectomy for metastatic carcinoma (1.4%) (p = 0.050). There was a significant difference in the incidence of space/organ SSIs between the patients with hepatolithiasis (11.9%) and HCC patients (3.6%) (p = 0.029), and between the patients with hepatolithiasis and metastatic carcinoma patients (1.4%) (p < 0.001). The rate of positive bile culture was 36.2% in all patients in this study, and the rates were 83.3, 7.8, and 10.0% for patients with hepatolithiasis, HCC, and metastatic carcinoma, respectively. A significantly higher (p < 0.001) positive bile culture rate was observed in patients with hepatolithiasis as compared with HCC or metastatic carcinoma patients. CONCLUSIONS: Our study suggests the existence of a relationship between postoperative SSIs and bile infection, thus supporting the proposed relationship between post-hepatectomy infection and such variables as liver function, blood sugar control, and nutritional status.

Assessment of liver function for successful hepatectomy in patients with hepatocellular carcinoma with impaired hepatic function.

BACKGROUND/PURPOSE: This study aimed to construct a formula for assessing liver function in order to prevent post-hepatectomy liver failure. METHODS: A formula was constructed by analyzing data from 28 patients with hepatocellular carcinoma (HCC) with liver cirrhosis operated on between 1981 and 1984. Next, we evaluated the validity of this formula in 207 hepatectomy patients operated on from 1985 to 1999. For 145 hepatectomy patients operated on from 2000 to 2006, this formula was calculated before surgery in order to assess their risk of hepatectomy. RESULTS: The formula for liver functional evaluation, constructed from preoperative hepatic function parameters, was: liver failure score = 164.8 - 0.58 x Alb - 1.07 x HPT + 0.062 x GOT - 685 x K. ICG - 3.57 x OGTT. LI + 0.074 x RW, where Alb is albumin (g/dl); HPT, hepaplastin test (%); GOT, glutamate oxaloacetate transaminase (U/l); K. ICG, K value of indocyanine green clearance test; OGTT. LI, 60-min/120-min glucose level in 75-g oral glucose tolerance test. linearity index of OGTT; and RW, weight of resected liver (g). We decided that a score below 25 would be safe for hepatectomy. CONCLUSIONS: The mortality rate decreased from 3.9% in 1985--1999 to 1.3% in 2000--2006. This finding allows us to conclude that the formula is valid for assessing the risk of post-hepatectomy liver failure.

Effect of normothermic perfusion using fructose-1,6-bisphosphate for maintenance of liver function during in situ extended hepatectomy by the total hepatic vascular exclusion technique.

BACKGROUND: Recently, hepatic surgery has made remarkable progress, and it is important to use appropriate liver perfusion. We evaluated the effect of normothermic liver perfusion with the addition of fructose-1, 6-bisphosphate (FBP) and oxygenation to maintain liver parenchymal, non-parenchymal, and Kupffer cell function. MATERIALS AND METHODS: The rats were divided into five groups according to the perfusate and continuous perfusion was performed: Control group = 4 degrees C lactate Ringer with 10% glucose (LRG) solution; normothermic group = 25 degrees C LRG solution; normothermic oxygenated group = 25 degrees C oxygenated LRG solution; normothermic FBP group = 25 degrees C LRG solution with addition of 10 mmol/L FBP; normothermic oxygenated FBP group = 25 degrees C oxygenated LRG solution with addition of 10 mmol/L FBP. Parameters under evaluation were oxygen consumption, liver energy level (adenosine triphosphate, total adenine nucleotide), glutathione, lipid peroxide, hyaluronic acid uptake ratio, apoptosis, and histomorphology. Moreover, we studied the effect of FBP and normothermia on Kupffer cells activation in vitro. RESULTS: Liver energy level was lower in the normothermic group than the control group. But, it was improved by oxidation or addition of FBP, and it was satisfactorily maintained up to 120 min in the group with normothermic oxygenated FBP. Hyaluronic acid uptake was maintained highly at all times as measured in normothermic oxygenated FBP group. The uptake of lipopolysaccharide was significantly higher as a result of adding FBP, compared with that in the control group and the normothermic group. Moreover, the apoptotic index in the liver was decreased in normothermic FBP group compared to control group. CONCLUSIONS: The normothermic liver perfusion under additional FBP and oxygenation protects both parenchymal and non-parenchymal cells from reperfusion injury.