Resection of hepatocellular carcinoma in patients without cirrhosis.

BACKGROUND: Outcomes for patients with hepatocellular carcinoma (HCC) without cirrhosis and factors associated with disease progression remain unclear. The goals of this single-institution study were to define the outcomes for such patients, and to determine factors associated with survival and disease progression. METHODS: This was a retrospective review of consecutive patients with HCC without cirrhosis who underwent hepatic resection between 1985 and 2003. Survival was estimated by the Kaplan-Meier method and risk factors were identified by Cox proportional hazards models. RESULTS: A total of 143 patients were enrolled, of whom 29·4 per cent had identifiable risk factors for chronic liver disease. Major resection (at least three segments) was undertaken in 63·6 per cent of patients. The operative mortality rate was 3·5 per cent. Median disease-free survival was 2·4 years. Multivariable analysis revealed presence of multiple tumours as the only independent predictor of tumour recurrence. Median overall survival was 3·3 years. Factors independently associated with decreased overall survival were multiple tumours, high histological grade, perioperative transfusion, male sex and age at least 66 years. CONCLUSION: Patients with HCC but without cirrhosis have acceptable outcomes after resection. Specific risk factors for the development of HCC in these patients have yet to be defined.

Treatment of neuroendocrine cancer metastatic to the liver: the role of ablative techniques.

Carcinoid tumors and islet cell neoplasms are neuroendocrine neoplasms with indolent patterns of growth and association with bizarre hormone syndromes. These tumors behave in a relatively protracted and predictable manner, which allows for multiple therapeutic options. Even in the presence of hepatic metastases, the standard of treatment for neuroendocrine malignancy is surgery, either with curative intent or for tumor cytoreduction, i.e., resection of 90% or more of the tumor volume. Image-guided ablation, as either an adjunct to surgery or a primary treatment modality, can be used to treat neuroendocrine cancer metastatic to the liver. Image-guided ablative techniques, including radiofrequency ablation, alcohol injection, and cryoablation, can be used in selected patients to debulk hepatic tumors and improve patient symptoms. Although long-term follow-up data are not available, the surgical literature indicates that significant ablative debulking may improve patient survival. In this review, we discuss metastatic neuroendocrine disease and its treatment options, especially image-guided ablative techniques.

Prospective evaluation of Roux-en-Y gastric bypass as primary operation for medically complicated obesity.

OBJECTIVE: To determine prospectively the results of Roux-en-Y gastric bypass (RYGB) used as the primary weight-reducing operation in patients with medically complicated ("morbid") obesity. The RYGB procedure combines the advantages of a restrictive physiology (pouch of 10 mL) and a "dumping physiology" for high-energy liquids without requiring an externally reinforced (banded) stoma. PATIENTS AND METHODS: Between April 1987 and December 1998, a total of 191 consecutive patients with morbid obesity (median weight, 138 kg [range, 91-240 kg]; median body mass index, 49 kg/m2 [range, 36-74 kg/m2]), all of whom had directly weight-related morbidity, underwent RYGB and prospective follow-up. RESULTS: Hospital mortality was 0.5% (1/191), and hospital morbidity occurred in 10.5% (20/191). Good long-term weight loss was achieved, and patients adapted well to the required new eating habits. The mean +/- SD weight loss at 1 year after operation (113 patients) was 52 +/- 1 kg or 68% +/- 2% of initial excess body weight. By 3 years postoperatively (74 patients), weight loss was still 66% +/- 2% of excess body weight. Overall, 53 (72%) of 74 patients had achieved and maintained a weight loss of 50% or more of their preoperative excess body weight 3 years after the operation. In addition, only 1 (1%) of 98 patients had persistent postoperative vomiting 1 or more times per week. CONCLUSION: We believe that RYGB is a safe, effective procedure for most patients with morbid obesity and thus may be the current procedure of choice in patients requiring bariatrics++ surgery for morbid obesity.

Hemosuccus pancreaticus complicating chronic pancreatitis: an obscure cause of upper gastrointestinal bleeding.

BACKGROUND: Hemosuccus pancreaticus, a rare form of upper gastrointestinal bleeding, may complicate chronic pancreatitis and pose a significant diagnostic and therapeutic dilemma. AIM: To present our experience with this potentially life-threatening complication of chronic pancreatitis. METHODS: We reviewed our experience with management (both operative as well as angiographic embolization) of patients with hemosuccus pancreaticus complicating histologically documented chronic pancreatitis between 1976 and 1997. Diagnosis of hemosuccus pancreaticus was based on clinical presentation, preoperative endoscopic and radiographic imaging, operative findings, and pathologic evaluation. RESULTS: During the period, we managed eight patients with hemosuccus pancreaticus (1.5% of all patients with chronic pancreatitis treated surgically). Gastrointestinal bleeding presented as hematemesis in three and hematochezia in three, but all had recent melena and were anemic; three of these patients were hemodynamically unstable. Abdominal pain was present in six. When performed, angiography (n=6) was diagnostic of a pseudoaneurysm; computed tomography (n=7) showed a pseudoaneurysm in two and a pseudocyst in five. Endoscopy (n=8) revealed blood issuing from the ampullary papilla in two patients. Operative management (n=6) involved distal pancreatectomy, pancreatoduodenectomy, or total pancreatectomy in two patients each. Angiographic embolization was successful in one patient, but the other died from uncontrollable hemorrhage. CONCLUSIONS: Hemosuccus pancreaticus is rare, but should be considered in patients with chronic pancreatitis and gastrointestinal bleeding. In the absence of pancreatitis-related indications for surgery, angiographic embolization can be definitive treatment. If there are pancreatitis-related indications for operation, angiographic embolization may allow an elective operative procedure based on structural changes of the pancreas. If embolization fails, pancreatic resection is usually required, often on an emergent basis.

Cholangiocarcinomas express Fas ligand and disable the Fas receptor.

Cholangiocarcinoma is a highly-malignant adenocarcinoma originating from cholangiocytes. Current concepts support escape from immune surveillance using aberrant expression of Fas ligand (FasL) and dysregulation of receptor (FasR) signaling as a potential mechanism for tumor progression. Our aims were to determine if altered expression of FasR and FasL or changes in expression of FLICE inhibitor (I-FLICE) allow cholangiocarcinoma cells to escape immune surveillance. Human cholangiocarcinoma cell lines were evaluated for the functional expression of FasR and FasL by (1) quantitating apoptosis after incubation of cells with agonistic antibodies and (2) an in vitro cell death assay involving coculture of cholangiocarcinoma cells with Fas-sensitive thymocytes. I-FLICE antisense treatment was performed by stable transfection with complementary DNA (cDNA) for I-FLICE in the reverse orientation. We found that normal cholangiocytes in vivo express FasL. Human cholangiocarcinoma cell lines express both FasL and FasR and I-FLICE. FasL expressed by cholangiocarcinomas in vitro induced lymphocyte cell death (70% after 24 hours). Despite the expression of FasR, exposure of the cells to agonistic antibodies (500 ng/mL) induced only minimal apoptosis in the Jurkat cells. Antisense treatment of cholangiocarcinomas in vitro with I-FLICE reduced protein expression of I-FLICE by 90% to 95% and increased Fas-mediated apoptosis 2-fold. We concluded that cholangiocarcinomas escape immune surveillance either by disabling FasR signaling through the expression of I-FLICE and/or increased FasL expression to induce apoptosis of invading T cells. Reduction of I-FLICE expression in cholangiocarcinoma cells restored Fas-mediated apoptosis. Therapeutic maneuvers to inhibit expression of I-FLICE may aid in the treatment of cholangiocarcinoma.

GUDC inhibits cytochrome c release from human cholangiocyte mitochondria.

Although ursodeoxycholic acid (UDC) is considered effective treatment for primary biliary cirrhosis (PBC), its mechanism of action is unclear. We tested the hypothesis that UDC is taken up by cholangiocytes and inhibits caspase 3-dependent apoptosis. We used the human cholangiocyte cell line (H69) and assessed it for expression and function of an apical sodium-dependent bile acid transporter (ASBT) by RT-PCR and uptake of tritiated taurocholic acid. We experimentally induced apoptosis in H69 cells using beauvericin (BV) and determined caspase 3 activation using a fluorogenic substrate and mitochondrial cytochrome c release (CC) into the cytosol by immunoblot analysis. We found that a functional ASBT is expressed by H69 cells as demonstrated by RT-PCR and bile acid uptake studies. Exposure of H69 cells to BV induced apoptosis in 39.4 +/- 1.3% of cells at 2 h (0.23 +/- 0.2% in controls). In contrast, when H69 cells were preincubated with GUDC (50 mM) for 24 h and then exposed to BV, apoptosis was inhibited by 23% (P < 0.03). In cholangiocytes pretreated with GUDC for 24 h and those treated with BV for 2 h, caspase 3-like activity was reduced by 79% and mitochondrial CC release was inhibited. In summary, the human cholangiocyte cell line H69 possesses a functional bile acid transporter, and GUDC decreases BV-induced apoptosis and inhibits activity of caspase 3 protease by blocking CC release from mitochondria. These preliminary results are consistent with our hypothesis that the beneficial effect of UDC on PBC may involve decreased apoptosis after GUDC uptake by cholangiocytes.

Glutathione depletion is associated with decreased Bcl-2 expression and increased apoptosis in cholangiocytes.

Cholangiocytes are the target of a group of liver diseases termed the cholangiopathies that include conditions characterized by periductal inflammation and cholangiocyte apoptosis. Because inflammation is associated with oxidative stress, we developed the hypothesis that cholangiocytes exposed to oxidative stress will be depleted of endogenous cytoprotective molecules, leading to cholangiocyte apoptosis. To begin to test this hypothesis, we explored the relationships among glutathione (GSH) depletion, expression of Bcl-2 (a protooncogene that inhibits apoptosis), and apoptosis in a nonmalignant human cholangiocyte cell line. Monolayers of human bile duct epithelial cells, derived from normal liver and immortalized by SV40 transformation, were depleted of GSH using buthionine sulfoximine (BSO). Bcl-2 expression was assessed by quantitative immunoblot analysis, and apoptosis quantified by fluorescence microscopy using the DNA binding dye 4', 6'-diamidino-2-phenylindole. Bcl-2 message was assessed by RNase protection assay, and Bcl-2 protein synthesis and half-life by pulse-chase analysis. Exposure of human cholangiocytes in culture to BSO reduced GSH levels by 93 +/- 3% (P < 0.01). In addition, treatment of cholangiocytes with BSO reduced Bcl-2 levels by 87 +/- 2% (P < 0.01) and was associated with a time-dependent increase in the number of cells undergoing apoptosis; approximately 11 +/- 1% of cultured cells demonstrated morphological changes of apoptosis by 72 h compared with 1.5 +/- 0.1% in untreated cholangiocytes (P < 0. 01). Maintenance of GSH levels by addition of glutathione ethyl ester in the presence of BSO blocked the BSO-associated increase in apoptosis in BSO-treated cholangiocytes and also prevented the decrease in Bcl-2 protein. BSO treatment of cholangiocytes did not change steady-state levels of bcl-2 mRNA or Bcl-2 protein synthesis. However, Bcl-2 protein half-life decreased 57% in BSO-treated vs. untreated cells. Our results using a human cholangiocyte cell line demonstrate that reduction in the cellular levels of an antioxidant such as GSH results in increased degradation of Bcl-2 protein and an increase in apoptosis. These data provide a mechanistic link between the consequences of oxidative stress and cholangiocyte apoptosis, an observation that may be important in the pathogenesis of the inflammatory cholangiopathies.

Dysregulation of apoptosis in the cholangiopathies and cholangiocarcinoma.

The importance of cholangiocytes, the epithelial cells lining bile ducts, in the biology and pathobiology of biliary epithelia is rapidly growing due to the advent of suitable experimental models and techniques to study these cells. However, the role of cholangiocytes as a major cellular target in a variety of severe hepatobiliary diseases or cholangiopathies remains unanswered. As the biology of cholangiocyte death evolves, apoptosis has emerged as a key player in the development of ductopenia in these cholangiopathies. Cholangiocytes are continuously exposed to a variety of genotoxic insults, such as chronic inflammation and hydrophobic bile acids. This chronic exposure may predispose cholangiocytes to oncogenic mutations and the further progression to malignancy (or cholangiocarcinoma [CC]), due, in part, to failure to activate apoptosis and delete cells with genetic damage.

Bcl-2 is overexpressed and alters the threshold for apoptosis in a cholangiocarcinoma cell line.

Cholangiocarcinoma is a malignant neoplasm originating from cholangiocytes. The mechanisms responsible for oncogenesis of cholangiocytes are unknown. Resistance to apoptosis, especially by altered expression of B-cell lymphoma/leukemia 2 (Bcl-2) family members, has been implicated as a mechanism contributing to malignant transformation. Thus, our aim was to test the hypothesis that altered expression of Bcl-2 family members by cholangiocarcinoma cells renders them resistant to apoptosis. We compared the apoptotic threshold and expression of the Bcl-2 protein family members, Bcl-2, Bcl-XL, and Bax, in two human cell lines: 1) nonmalignant human cholangiocytes immortalized by transfection with the simian virus 40 (SV 40) large T antigen; and 2) a malignant human cholangiocarcinoma cell line. Apoptosis was induced pharmacologically using beauvericin. Bcl-2, Bcl-x long, and Bax protein expression were evaluated by immunoblot analysis, and Bcl-2 expression was modulated using antisense technology. The cholangiocyte and malignant/nonmaligant phenotype of both cell lines was verified using both in vitro and in vivo approaches. Beauvericin induced apoptosis of nonmalignant cholangiocytes in a concentration- (0 to 25 micromol/L) and time- (0 to 6 hours) dependent manner. In contrast, malignant cholangiocytes were resistant to apoptosis. Although expression of Bcl-x long and Bax protein were similiar in the two cell lines, Bcl-2 protein expression was 15-fold greater in malignant than in nonmalignant cholangiocytes. An 18 mer bcl-2 antisense oligonucleotide reduced expression of Bcl-2 protein by 50% and increased the rate of beauvericin-induced apoptosis more than threefold in the malignant cells. Our results support the hypothesis that resistance to apoptosis by overexpression of Bcl-2 may be a feature of cholangiocarcinoma.

Hepatocytes in the bile duct-ligated rat express Bcl-2.

Hepatocytes do not express Bcl-2, a repressor of apoptosis. In contrast, cholangiocytes, which are in direct contact with bile, do express Bcl-2. Because cholestasis results in the retention of bile within hepatocytes, we reasoned cholestasis may induce hepatocellular expression of Bcl-2. Thus our aim was to determine whether hepatocytes express Bcl-2 or alter expression of other Bcl-2 family members in cholestasis using the bile duct-ligated (BDL) rat as a model of cholestasis. De novo Bcl-2 expression was observed in hepatocytes of BDL rats assessed by reverse transcriptase-polymerase chain reaction and immunoblot analysis. Immunohistochemistry demonstrated that Bcl-2 expression in hepatocytes was greater in periportal hepatocytes than pericentral hepatocytes. Expression of Bcl-x (an antiapoptotic Bcl-2 family protein) was not altered by bile duct ligation, whereas expression of Bax (a proapoptotic Bcl-2 family protein) increased slightly as determined by Northern and Western blot analyses. Bcl-2-positive hepatocytes isolated from BDL rats were resistant to induction of apoptosis by 50 microM glycochenodeoxycholate. Our results demonstrate, for the first time, expression of Bcl-2 by hepatocytes during cholestasis. We suggest that hepatocellular expression of Bcl-2 during cholestasis is an adaptive phenomenon to resist apoptosis by toxic bile salts.

Development and initial application of an in vitro model of apoptosis in rodent cholangiocytes.

Although histological data suggest that cholangiocytes die by apoptosis in human liver diseases, no information exists on the mechanisms of cholangiocyte apoptosis. Thus our aims were to establish an in vitro model of cholangiocyte apoptosis and to test the hypothesis that changes in intracellular ions would cause apoptosis in cholangiocytes by a protease-sensitive pathway. A large number of proapoptotic agents were ineffective in inducing apoptosis in rat or human cholangiocytes in culture; in contrast, beauvericin, a K+ ionophore, caused apoptosis in both cell lines, despite their expression of Bcl-2. Although beauvericin decreased intracellular K+ and increased intracellular Ca2+, abolishing the K+ gradient did not prevent beauvericin-induced apoptosis; in contrast, omission of extracellular Ca2+ inhibited apoptosis by 42%. The interleukin-1 beta-converting enzyme (ICE) family protease inhibitor, Z-Val-Ala-Asp chloromethylketone, inhibited apoptosis in a concentration-dependent manner. By Northern blot analysis, cholangiocytes expressed the mRNA for three members of the ICE protease family: ICE, ICE/ CED-3 homologue-1 (ICH-1), and cysteine protease P-32 (CPP-32). Cleavage of a substrate for CPP-32-like protease activity, but not a substrate for ICE and ICH-1, increased after beauvericin treatment. In summary, we have established an in vitro model of apoptosis in cholangiocytes. Our data suggest that beauvericin-induced apoptosis occurs by a Ca(2+)-dependent CPP-32 protease-sensitive pathway despite cholangiocyte expression of Bcl-2.

Cell death by apoptosis: basic concepts and disease relevance for the gastroenterologist.

We have reviewed in a conceptual manner with appropriate scientific detail the role apoptosis plays in diseases of the gastrointestinal tract. This information should help the clinician and clinician investigator to better understand and treat gastrointestinal diseases. Future investigations in apoptosis probably will provide further insight into the cell-signaling cascades regulating apoptosis, the mechanism(s) by which Bcl-2 inhibits apoptosis, and the precise role of apoptosis in cancer initiation, promotion, and progression. We anticipate that in the future, the practicing gastroenterologist will have therapeutic strategies available to inhibit apoptosis for various gastrointestinal diseases associated with cell death and to induce apoptosis for the treatment of gastrointestinal neoplasia.

Hepatic resection for metastatic neuroendocrine carcinomas.

BACKGROUND: Metastatic neuroendocrine malignancies frequently cause incapacitating endocrinopathies, and metastases predominant in the liver. Hepatic resection of metastases from such tumors is attractive because the natural history of neuroendocrine tumors is protracted, clinical severity of the endocrinopathy correlates with tumor volume, and local and intrahepatic growth characteristics often allow complete resection. PATIENTS AND METHODS: To define the role of hepatic resection for metastatic neuroendocrine tumors, the records of 74 patients who underwent hepatic resection for such tumors between 1984 and 1992 were reviewed. Neuroendocrine tumors were classified by site of origin and clinical endocrinopathy. Survival, and type and duration of symptomatic response, were assessed as the major outcomes of this study. RESULTS: There were 50 carcinoid, 23 islet-cell, and 1 atypical neuroendocrine tumors. Resections included 36 hemihepatectomies or extended hepatectomies and 38 nonanatomic resections. Thirty-eight primary tumors were resected concomitantly. Perioperative mortality was 2.7% and morbidity was 24%. Four-year survival was 73%. Overall postoperative symptomatic response rate was 90% with a mean duration of response of 19.3 months. CONCLUSIONS: Hepatic resection for metastatic neuroendocrine malignancies is safe, provides effective palliation, and probably prolongs survival.

Resection of 'recurrent' colorectal metastases to the liver.

Hepatic resection is the only treatment for patients with colorectal cancer metastatic to the liver that has resulted in long-term survival. This apparent efficacy of hepatectomy has prompted efforts to expand the surgical approach for disease progression within the liver. A review of personal experience and of the literature was performed in an attempt to define the role of surgery for disease progression. Twenty-one patients who underwent hepatic resection between 1983 and 1991 for isolated disease progression in the liver were retrospectively reviewed. The median follow-up of patients still alive was 1.7 years (range 4 months to 4.5 years). The median survival from the date of repeat hepatic resection was 3.4 years with an estimated actuarial survival rate of 43 per cent at 4 years. These patients experienced no significant morbidity and the mortality rate was 5 per cent. Hepatic resection of metastatic colorectal carcinoma can produce long-term survival without prohibitive risk. These findings support an aggressive surgical approach for metastatic progression in the liver from colorectal carcinoma.