Mesenteric arterioportal shunt after hepatic artery interruption.

BACKGROUND: Massive hepatic necrosis from hepatic artery (HA) interruption is a complication after extended pancreatobiliary operation. The effectiveness of a mesenteric arterioportal shunt in preventing liver failure after massive hepatic necrosis was evaluated. METHODS: Of 98 patients who underwent pancreatic or hepatic resection for pancreatobiliary carcinoma between January 1989 and December 1995, six received a mesenteric arterioportal shunt. Clinical and hemodynamic analyses were done retrospectively. RESULTS: The six patients were classified into groups: A, postoperative hepatic arterial occlusion and, B, main HA excision without reconstruction. One patient in group A and three patients in group B had good arterioportal shunt patency and favorable clinical courses. However, fatal hepatic necrosis after ligation of the HA proper occurred in one patient in group A from small portal flow despite a presumed patent shunt. In another patient in group A angiogram revealed shunt occlusion. CONCLUSIONS: A mesenteric arterioportal shunt is beneficial when massive hepatic necrosis has occurred or is expected after main HA interruption under such conditions as postoperative hepatic arterial occlusion or HA excision without reconstruction. The procedure has the advantages of appropriate selection of artery size, a lower abdominal site apart from the primary operative field, and easy shunt closure by transarterial embolization.

Cysteine-S-conjugate beta-lyase activity and pyridoxal phosphate binding site of onion alliin lyase.

Purification of onion alliin lyase gave two fractions by cation exchange chromatography. Both fractions showed the comparable high catalytic activity of cysteine-S-conjugate beta-lyase with that of alliin lyase using S-(2-chloro-6-nitrophenyl)-L-cysteine and alliin, S-allyl-L-cysteine sulfoxide as substrates. All the active substrates tested with onion alliin lyase were also active to the cysteine-S-conjugate beta-lyase of Mucor javanicus, but the catalytic activity of the Mucor enzyme was lower for all the substrates. The pyridoxal phosphate binding site of the onion alliin lyase was identified as Lys 285 in the amino acid sequence deduced from cDNA which has been reported. This lysine was conserved in all the sequences from the alliin lyase cDNAs, while similarity was not found between the sequences around pyridoxal phosphate binding sites of both the onion alliin lyase and the Mucor cysteine-S-conjugate beta-lyase.

Plasma adsorption to charcoal and ion-exchange resin for treating postoperative hepatic failure.

Postoperative hepatic failure was treated by plasma adsorption (PA) to charcoal and ion-exchange resin in five patients suffering from pancreatic or biliary carcinoma that was not accompanied by liver cirrhosis. Four of these patients recovered completely from the hepatic failure, while the fifth patient recovered sufficiently to be taken off the treatment for three weeks. Reactions in platelet counts and circulatory system during and after the PA treatment were minimal in all these patients. PA proved to be an effective liver support system for treating non-cirrhotic patients with postoperative hepatic failure.

Partial portal arterialization for the prevention of massive liver necrosis following extended pancreatobiliary surgery: experience of two cases.

Massive liver necrosis, which is a severe and highly fatal complication after extended pancreatobiliary surgery, may occur due to an interruption of the hepatic arterial flow caused by such events as an excision of the hepatic artery invaded by cancer, a ligation of the postoperatively ruptured hepatic artery, or a thrombotic obstruction of the reconstructed hepatic artery. In order to improve this ischemic state of the liver, we have performed a partial arterialization of the portal vein by making an arteriovenous shunt at the mesenteric vascular branches in two cases. Although a sufficient pathophysiological investigation could not be fully conducted, partial portal arterialization was considered to be effective in one patient, while no clinically noticeable adverse effects were revealed in the other patient.

[Prognosis of intra-arterial chemo-embolization in metastatic liver cancer].

We treated 63 patients (pts) suffering from metastatic liver cancer with intra-arterial infusion chemotherapy, and analysed 44 of their for survival since the first treatment with regard to the primary foci of cancer and the method of intra-arterial therapy. Via the superficial femoral artery, we performed superselective hepatic catheterization by Seldinger's method. Three types of intraarterial therapy were used: Gelfoam embolization with mitomycin-C (MMC) in 12 pts (GS-TAE), capillary chemo-embolization with MMC-Lipiodol emulsion in 28 pts (LP-TAI) and "one-shot" slow infusion of MMC or cisplatinum in 4 pts. Fifty-percent survival was 189 days in pts with metastases from colo-rectal cancer (n = 20), 109 days from gastric cancer (n = 9), 100 days from pancreatobiliary cancer (n = 5) and 240 days from breast cancer (n = 7). More than one-year survival was obtained in 13 out of the 40 pts (32.5%). Survival of 12 pts, treated with GS-TAE regimen, was not significantly superior to that of 28 pts with LP-TAI regimen. Hence, we conclude that LP-TAI is the treatment of choice in chemo-embolization for unresectable liver metastases, because it causes less damage to the hepatic arterial beds, and facilitates repeat intraarterial therapy in these pts.

Gastric leiomyoblastoma: report of a case.

The case of a 38-year-old man with an exogastric leiomyoblastoma is reported. CT and ultrasound examinations revealed a large mass in the left hypochondrium that had both solid and cystic components. These findings mimicked those of cystadenoma of the pancreas. Because of intraperitoneal hemorrhage in the preoperative course, emergency laparotomy was performed. A large tumor was found to arise from the greater curvature of the stomach. The diagnosis was confirmed histologically.

[Experimental study on intrahepatic gas tensions measured by mass spectrometry: effect on temporary occlusion of the afferent hepatic circulation].

In 24 mongrel dogs, a mass spectrometer was utilized to measure intrahepatic pO2 and pCO2 levels subjected to various degrees of inspired oxygen concentration, or interruption of the afferent hepatic circulation. The mean intrahepatic pO2 and pCO2 levels in dogs breathing 70% O2 were 46.0 +/- 13.3(SD) mmHg and 27.4 +/- 13.0mmHg, respectively. Progressive rise of the intrahepatic pO2 and pCO2 was observed with increase in the arterial pO2 and pCO2 when the hepatic circulation was kept constant. When the hepatic artery was interrupted, mean intrahepatic pO2 fell rapidly to 20% of the control value, and mean intrahepatic pCO2 rose to 200%. Rather wide dispersion of the values among the experimental animals during the hepatic artery interruption was speculated to reflect the variety of collateral hepatic arterial supply and various degrees of congestion of portal blood flow. Transient decrease in the mean intrahepatic pO2 was observed following interruption of the portal vein. Intrahepatic pO2 rapidly fell to zero and pCO2 increased in a lineal fashion when the total hepatic circulation was interrupted. The latter rose to 453% of the control value 30 minutes after interruption, then the rate of rise gradually decreased until a plateau was reached one hour later. This decrease in the rate of rise in intrahepatic pCO2 was regarded to reflect the reduction of energy production through the anerobic pathway due to irreversible hepatic parenchymal degeneration. It is suggested that the measurement of intrahepatic gas tensions under various conditions by a mass spectrometer technique is useful for evaluating changes of intrahepatic microcirculation and dynamic aspects of anerobic metabolism of the liver.

Hepatic artery aneurysm. Report of a case and review of the literature.

One hundred and nineteen cases, including the one reported here, of hepatic artery aneurysm were reviewed. The clinical features and surgical management in four etiologic groups, consisting of arteriosclerosis, cholecystolithiasis, trauma and, specific diseases, were investigated. Interruption of the hepatic artery, entailing ligation of the hepatic artery, excision of the aneurysm without vascular reconstruction, and obliterative aneurysmorrhaphy, was done in 50 patients. Its high mortality rate (26%) was principally ascribed to delayed diagnosis or inappropriate site of interruption. If conditions such as shock, anoxia and portal thrombosis are avoided, interruption of the hepatic artery seems to be a safe and useful operative method for hepatic artery aneurysms, especially accompanied by severe local infection.

Duplication of common bile duct--a case report.

A case of double common bile duct is presented. Precise preoperative recognition of this anomaly is extremely rare. Preoperative adequate appreciation of these anomalies of the biliary tree prevents surgeons from impairing the anomalous bile ducts, or from going astray, being faced with these anomalies at operation accidentally.