Aspartate aminotransferase-to-platelet ratio index is associated with liver cirrhosis in patients undergoing surgery for hepatocellular carcinoma.

BACKGROUND: Among various preoperative evaluations of liver function, accurate assessment of liver cirrhosis (LC) is especially important in patients undergoing surgery for hepatocellular carcinoma (HCC). OBJECTIVE: To explore the most significant laboratory parameter associated with LC in patients undergoing surgery for HCC. METHODS: From among 588 HCC patients in our collected database who underwent liver surgery, 371 for whom sufficient laboratory data were evaluable, including direct serum fibrosis markers such as hyaluronic acid and type 3 procollagen peptide (P-3-P), were enrolled. Receiver operating characteristic (ROC) curve analysis was used to define the ideal cutoff values of laboratory parameters, and the area under the ROC curve for LC was measured. Univariate and multivariate analyses were performed to clarify the laboratory parameter most significantly associated with LC. RESULTS: Multivariate analysis of 13 laboratory parameters that had been selected by univariate analysis showed that the aspartate aminotransferase-to-platelet ratio index (APRI) (≤ 0.8/>0.8) (odds ratio, 2.687; 95% confidence interval 1.215-5.940; P = 0.015) was associated with LC, along with the aspartate aminotransferase to alanine aminotransferase ratio, the indocyanine green retention ratio at 15 min (ICG R15), and the level of hyaluronic acid. Among these four parameters associated with LC, ROC curve analysis revealed that APRI (0.757) had the largest area under the ROC (aspartate aminotransferase to alanine aminotransferase 0.505, ICG R15 0.714, and hyaluronic acid 0.743). CONCLUSIONS: APRI is closely associated with LC in patients undergoing surgery for HCC.

When hepatic-side ductal margin is positive in N+ cases, additional resection of the bile duct is not necessary to render the negative hepatic-side ductal margin during surgery for extrahepatic distal bile duct carcinoma.

BACKGROUND: The current standard treatment for extrahepatic distal bile duct carcinoma (EDBDC) is surgical resection, as no effective alternative treatment exists. In this study, we investigated the treatment strategies and outcomes for 90 cases of EDBDC at our department. MATERIAL AND METHODS: Between April 2000 and March 2013, 90 pancreatoduodenectomies (PDs) were performed for EDBDC. The mean patient age was 69.1 ± 9.8 years, and there were 59 males and 31 females. Extended lymph adenectomy including lymph nodes around the common hepatic artery and celiac axis was performed in all patients. The mean operation time was 537.1 ± 153.8 min and the mean operative blood loss was 814.0 ± 494.0 ml. There were no operation-related deaths. The overall 1-, 3-, and 5-year survival rates were 90.0%, 51.2%, and 45.0%, respectively. RESULTS: Lymph node metastasis was present in 28 patients (N+; 31.1%), and it was absent in 62 (N-; 68.9%). The 5-year survival rate was 20.0% for N+ patients and 52.4% for N- patients, which is significantly higher (P=0.03). Nine cases (10.0%) showed hepatic-side ductal margin (HM) positivity for carcinoma. The 5-year survival rate was 18.7% for HM-positive patients and 48.3% for HM-negative patients, which is significantly higher (P=0.005). In multivariate analysis, N+ was the strongest adverse prognostic factor. Subclass analysis of 62 cases (excluding 28 N+ cases) revealed 7 patients with positive HMs (11.3%) and 55 patients with negative HMs (88.7%). The 5-year survival rate was 47.6% for HM-positive patients and 49.8% for HM-negative patients (P=0.73). Thirty-five cases (38.9%) recurred: there were 19 cases of local recurrence (21.1%), 11 cases of liver metastasis (12.2%), 4 cases of distant recurrence (4.4%), and 1 case of para-aortic lymph node metastasis (1.1%). CONCLUSIONS: In conclusion, when HM is positive in N+ cases, additional resection of the bile duct is not necessary to render the HM negative for carcinoma.

Effect of billroth II or Roux-en-Y reconstruction for the gastrojejunostomy on delayed gastric emptying after pancreaticoduodenectomy: a randomized controlled study.

OBJECTIVE: Delayed gastric emptying (DGE) is one of the major complications after pancreaticoduodenectomy (PD), occurring in 14% to 61% of cases. There have been no studies that compare the incidence of DGE in terms of the reconstruction method of gastrojejunostomy performed in subtotal stomach-preserving pancreaticoduodenectomy (SSPPD). The objective of this study was to evaluate the superiority of Billroth II (B-II) to Roux-en Y (R-Y) reconstruction on decreasing the incidence of delayed gastric emptying DGE after SSPPD by a prospective randomized controlled trial. METHODS: Between April 2008 and August 2011, 101 patients who underwent SSPPD for pancreatic head or periampullary diseases were randomly allocated to B-II reconstruction (n = 52) and R-Y reconstruction (n = 49) groups. The primary endpoint was incidence of DGE. RESULTS: DGE occurred in 5.7% of patients in the B-II group and in 20.4% of patients in the R-Y group (P = 0.028). Patients in the B-II group had a significantly shorter hospital stay after operation than patients in the R-Y group (31.6 ± 15.0 days vs. 41.4 ± 20.5 days, P = 0.037). In terms of postoperative complications, the incidence of pancreatic fistula was significantly higher in patients with DGE (38.5%) than in patients without DGE (14.8%) (P = 0.037). CONCLUSION: It is suggested that the incidence of DGE after SSPPD can be decreased by using B-II rather than R-Y reconstruction for gastrojejunostomy.(Clinical Trials Registry, UMIN-CTR: http://www.umin.ac.jp/ctr/, ref no. UMIN000003535).

Patient with adult-onset type II citrullinemia beginning 2 years after operation for duodenal malignant somatostatinoma: Indication for liver transplantation.

We report a 51-year-old female patient with adult-onset type II citrullinemia (CTLN2) who had a history of pancreatoduodenectomy for duodenal somatostatinoma with metastases to regional lymph nodes at age 49 years, paying special attention to indications for liver transplantation. At age 50 years, she developed hepatic encephalopathy with elevation of plasma ammonia and citrulline levels. A diagnosis of CTLN2 was made by DNA analysis of the SLC25A13 gene and treatment with conservative therapies was begun, including a low-carbohydrate diet and supplementation with arginine and sodium pyruvate. However, despite these treatments, frequent attacks of encephalopathy occurred with markedly elevated plasma ammonia levels. While we were apprehensive regarding the risk of recurrence of somatostatinoma due to immunosuppressive therapy after liver transplantation, the patient was in a critical condition with CTLN2 and it was decided to perform living-donor liver transplantation using a graft obtained from her son. Her postoperative clinical course was uneventful and she has had an active life without recurrence of somatostatinoma for 2 years. This is the first case of CTLN2 with somatostatinoma. As the condition of CTLN2 patients with rapidly progressive courses is often intractable by conservative therapies alone, liver transplantation should be considered even after surgery for malignant tumors in cases with neither metastasis nor recurrence.

Single-stage intraoperative transhepatic biliary stenting in patients with unresectable hepatobiliary pancreatic tumors.

BACKGROUND: The current study was conducted to evaluate the safety and utility of intraoperative transhepatic biliary stenting (ITBS) in patients with unresectable malignant biliary obstruction (UMBO) diagnosed intraoperatively. METHODS: In this study, 50 patients who underwent ITBS for UMBO between April 2001 and May 2009 were retrospectively reviewed. For 26 patients who underwent preoperative percutaneous transhepatic biliary drainage (PTBD), the expandable metallic stent (EMS) was inserted intraoperatively by the PTBD route in a single stage. For 24 patients, the intrahepatic bile ducts were intentionally dilated by injection of saline via the endoscopic nasobiliary drainage or the percutaneous transhepatic gallbladder drainage route, and the puncture was performed under intraoperative ultrasound guidance followed by guidewire and catheter insertion. Thereafter, the EMS was placed in the same manner. The initial postoperative complications and long-term results of ITBS were evaluated. RESULTS: In all cases, ITBS was technically successful. Stenting alone was performed in 22 patients and stenting combined with other procedures in 28 patients. Hospital mortality occurred for three patients (6 %), and complication-related mortality occurred in two cases (4 %). There were nine cases (18 %) of postoperative complications. The median survival time was 179 days, and the EMS patency time was 137 days. During the follow-up period, EMS occlusion occurred in 23 cases (46 %). Best supportive care was a significant independent risk factor for early mortality within 100 days after ITBS (p = 0.020, odds ratio, 9.398). CONCLUSIONS: Single-stage ITBS is feasible for palliation of UMBO and seems to have a low complication rate.

Usefulness of an inflammation-based prognostic score (mGPS) for predicting survival in patients with unresectable malignant biliary obstruction.

BACKGROUND: An inflammation-based prognostic score, the modified Glasgow Prognostic Score (mGPS), has been established as a useful tool for predicting postoperative outcome in patients with cancer. However, no studies have investigated the usefulness of the mGPS for prognostication in patients undergoing palliative surgery for unresectable malignant biliary obstruction (UMBO). The present study was conducted to investigate whether the mGPS is useful for predicting the postoperative survival of patients undergoing intraoperative placement of an expandable metal stent for UMBO, or not. METHODS: The mGPS was calculated as follows: patients with both an elevated level of C-reactive protein (CRP) (>1.0 mg/dL) and hypoalbuminemia (<3.5 g/dL) were allocated a score of 2. Patients with only an elevated CRP level were allocated a score of 1, and patients without an elevated CRP level (≤1.0 mg/dL) were allocated a score of 0. Postoperative survival was evaluated by Kaplan-Meier analysis and log rank test. The significance of risk factors for postoperative survival was evaluated with the Cox proportional hazards model. RESULTS: Kaplan-Meier analysis revealed that patients with mGPS 0 (n = 36) and 1 (n = 7) had better postoperative survival (p = 0.017) than patients with mGPS 2 (n = 17). The 6-month and 1-year survival rates of patients with mGPS 0 and 1 were 58.1 and 27.3 %, and those for patients with mGPS 2 were 25.0 and 6.2 %, respectively. Multivariate analysis revealed that mGPS (0, 1/2) was a significant risk factor for postoperative survival (hazard ratio 3.271; 95 % CI 1.109-9.649; p = 0.032). CONCLUSION: The mGPS is not only one of the most significant predictors of postoperative survival for UMBO patients receiving intraoperative biliary stenting but also a useful indicator capable of dividing such patients into two independent groups before surgery.

Results of pancreaticoduodenectomy with portal or superior mesenteric vein resection for locally advanced pancreatic head cancer.

BACKGROUND/AIMS: It is known that portal vein (PV) or superior mesenteric vein (SMV) is easily invaded by locally advanced pancreatic head cancer due to anatomical characteristics. Few studies have investigated the results of PD with PV or SMV resection (PVR) for pancreatic head cancer. METHODOLOGY: We retrospectively reviewed a database of 83 patients who had undergone PD for pancreatic head cancer (PC). We divided them into two groups, a group with PD and PVR (PD +PVR G) and a group with PD and no PVR (PD -PVR G). The clinicopathological findings and mortality were analyzed. RESULTS: Twenty-nine of the 83 patients (34.9%) needed PD with PVR. Median survival and disease free survival were 20.4 months and 10.6 months, respectively. The 5-year overall survival rate was 8.1% in PD +PVR G and 7.4% in PD -PVR G, respectively. There was no difference between the two groups (p = 0.091, HR: 1.576; 95% CI: 0.9299-2.670). The 5-year disease free survival rate was 9.6% in PD +PVR G and 10.2% in PD -PVR G, respectively. Also, there was no difference between the two groups (p = 0.206, HR: 1.414; 95% CI: 0.8264-2.420). CONCLUSIONS: Since PVR by itself is not a risk factor of postoperative morbidity and mortality and contributes to improving 5-year overall survival and disease free survival, PVR should be done for selected cases with locally advanced pancreas head cancer.

Discrepancy of B cell frequency between periphery and spleen after rituximab treatment in ABO-incompatible liver transplantation.

ABO-incompatible living-donor liver transplantation (ABO-LDLT) is generally more difficult to perform than ABO-incompatible kidney transplantation. Despite introduction of rituximab, ABO-LDLT in non-responders is a still difficult issue. A 23-year-old woman with primary sclerosing cholangitis underwent LDLT. The recipient's blood type was 0(+) and the donor's was B(+). Rituximab was infused twice on preoperative day (POD) 14 and 7. Plasma exchange (PE) was performed on PODs 5, 3, 2, and 1. However, repeated PE failed to decrease the anti-B antibody titer. On the other hand, preoperative esophagogastroscopy revealed esophageal varices with red color sign. Therefore, simultaneous liver transplantation and Hassab operation were performed. The donor left lobe of the liver was orthotopically transplanted into the recipient following Hassab operation. Flow cytometry on the day of surgery showed that the frequencies of B cells (CD20+) and memory B cells (CD20+/CD27+) in the peripheral blood were 0.9% and 0.3%, respectively; flow cytometry of cells recovered from the spleen revealed that the frequencies of B cells and memory B cells were 2.5% and 2.4%, respectively. Acute cellular rejection occurred on POD 15, and was treated by steroid pulse therapy, leading to a decrease in the anti-B antibody titer. The liver was functioning well on POD 390 (AST 19, ALT 34). In non-responders to ABO-LDLT, anti-donor blood type antibody-producing cells remains in the spleen after the conventional preoperative regimen. Splenectomy is an option for ABO-LDLT non-responders.

Surgical inflammation induces hepcidin production after abdominal surgery.

BACKGROUND: Hepcidin, a key regulator of iron homeostasis, is also a marker of acute inflammation. In the present study we investigated the changes in the serum hepcidin level and correlations between hepcidin and other markers of acute inflammation during the perioperative period in patients after abdominal surgery. METHODS: Serum hepcidin, hemoglobin (Hb), hematocrit (Ht), white blood cell (WBC) count, frequency of neutrophils, and C-reactive protein (CRP) were measured preoperatively (Pre), and on postoperative days (POD) 1, 3, 7, and 14. RESULTS: In patients undergoing gastrectomy, the median levels of hepcidin preoperatively and on POD 1, 3, 7, and 14 were 6.5, 53.1, 31.7, 15.6, and 4.0 ng/dl, respectively (p < 0.0001). The corresponding levels in colectomy patients were 8.5, 78.3, 60.1, 49.7, and 8.4 ng/dl, respectively (p = 0.0002); those in hepatectomy patients were 6.6, 16.3, 3.5, 13.4, and 3.4 ng/dl, respectively (p = 0.0022); and those in patients undergoing surgery for diffuse peritonitis were 24.8, 50.1, 43.1, 31.2, and 31.7 ng/dl, respectively (p = 0.4933). There were no significant decreases in Hb and Ht in the patients undergoing gastrectomy, colectomy, or surgery for diffuse peritonitis. The level of hepcidin was significantly correlated with the WBC count, frequency of neutrophils, and CRP level during the perioperative period for all four types of operation. CONCLUSIONS: Like other inflammatory markers, an increase in the level of hepcidin (i.e., a hepcidin storm) occurs in the acute phase after gastrectomy, colectomy, hepatectomy, and surgery for diffuse peritonitis.

Intraoperative observation using a fluorescence imaging instrument during hepatic resection for liver metastasis from colorectal cancer.

BACKGROUND/AIMS: We have found that liver metastasis from colorectal cancer (LM-CRC) can be easily detected by its fluorescence using a fluorescence imaging instrument (photodynamic eye (PDE)) in patients who have received an intravenous injection of indocyanine green (ICG). Therefore, our aim is to demonstrate the usefulness of PDE observation for hepatic resection in patients with LM-CRC. METHODOLOGY: Between February and October 2009, seven patients who underwent hepatic resection for LM-CRC were enrolled. After previous ICG injection (0.1mg/kg/mL), PDE observation was performed to detect fine invisible residual tumors on the surface of the resected liver. RESULTS: All of the 46 resected LM-CRCs that had been pointed out preoperatively were easily detected by their fluorescence using PDE observation. Three of the seven patients underwent additional partial resection because fine invisible residual tumors were detected by their fluorescence using PDE observation. All of these patients who underwent additional resection had no recurrence of LMCRC on the surface of the resected liver after surgery. CONCLUSIONS: PDE observation is useful for detecting fine invisible residual tumors that cannot be revealed under visible light during hepatic resection in patients with LM-CRC and may reduce the incidence of local recurrence on the superficial parenchyma of the liver.

Impact of grading of liver metastasis on postoperative outcome in patients with liver metastases from colorectal cancer.

BACKGROUND/AIMS: Few studies have investigated grading of liver metastasis (GLM) in patients with liver metastases from colorectal cancer (LM-CRC). METHODOLOGY: To screen for the most useful predictive factors in patients undergoing hepatic resection for LM-CRC, clinico-pathological factors were subjected to uni- and multivariate analyses. RESULTS: One hundred and twenty-five patients were evaluated retrospectively. Univariate analyses using clinico-laboratory factors demonstrated that nomogram, gender, CRP, albumin, number of hepatic resections, liver metastasis (H) and GLM were related to postoperative death. Multivariate analysis using these seven factors disclosed that albumin (OR, 6.949; 95% CI, 1.994-24.22; p=0.002), CRP (OR, 6.977; 95% CI, 1.937-25.14; p=0.003) and GLM (OR, 2.819; 95% CI, 1.082-7.346; p=0.034) were associated with postoperative death. Kaplan-Meier analysis and log rank test revealed that higher GLM (p<0.001) and CRP (p<0.001) were associated with a higher rate of postoperative death. GLM was able to divide the patients into three independent groups with significantly different total nomogram counts (p<0.001, Kruskal-Wallis test). CONCLUSIONS: GLM is able to classify patients with LM-CRC into three independent groups and offers reliable information for predicting postoperative death in such patients.

Usefulness of a modified inflammation-based prognostic system for predicting postoperative mortality of patients undergoing surgery for primary hepatocellular carcinoma.

OBJECTIVE: To assess and compare the predictive values of the hepatic Glasgow Prognostic Score (hGPS) and Cancer of the Liver Italian Program (CLIP) score in patients undergoing surgery for primary hepatocellular carcinoma (HCC). METHODS: The hGPS was calculated as follows: patients with an elevated level of C-reactive protein (CRP) (>0.3 mg/dl) were allocated a hGPS of 1 or 2 depending on the absence or presence of hypoalbuminemia (<3.5 g/dl), and patients without an elevation of the CRP level (≤ 0.3 mg/dl) were allocated a hGPS of 0. RESULTS: Three hundred patients were evaluated. The hGPS divided patients into three independent groups, and that a hGPS of 2 predicted a higher mortality rate (P < 0.001) than a hGPS of 0 or 1. Univariate analysis demonstrated that hGPS (0, 1/2) (P = 0.010) was one of the factors predictive of postoperative mortality, along with the CLIP score (0, 1/≥ 2) (P = 0.021). Comparative analysis using these two factors showed that the hGPS was predictively superior to the CLIP score (P = 0.033). CONCLUSIONS: The hGPS is able to divide patients undergoing surgery for primary HCC into three independent groups, and is considered to be an important factor predictive of postoperative mortality in such patients.

Underweight patients show an increased rate of postoperative death after surgery for hepatocellular carcinoma.

OBJECTIVE: To evaluate the influence of body mass index (BMI) on postoperative death in patients undergoing surgery for HCC. METHODS: Three hundred forty-two patients were enrolled, and divided into three groups: Group A, BMI <22.5; Group B, BMI ≥22.5 to <25; Group C, BMI ≥25. Univariate and multivariate analyses of postoperative death were performed to compare BMI with clinical factors. Kaplan-Meier analysis and log rank test were used to compare such outcome in Groups A, B, and C. RESULTS: Kaplan-Meier analysis and log rank test revealed that Group A had a higher rate of postoperative death than Group B or C (P = 0.010). Univariate and multivariate analyses selected being underweight (Group B, C/Group A) (odds ratio, 1.829; 95% C.I., 1.091-3.068; P = 0.022) as one of the factors predictive of postoperative death, together with aspartate aminotransferase level (P = 0.042) and HCC growth pattern (P = 0.032). CONCLUSIONS: BMI is a simple but important predictor of postoperative death in patients undergoing surgery for HCC, and is able to classify such patients into three independent groups.

Clinical outcome of hepatectomy for hepatocellular carcinomas≤2 cm.

BACKGROUND: The treatment strategy for hepatocellular carcinomas (HCCs)≤2 cm (HCC2-) is still controversial. In this study, we retrospectively analyzed clinicopathological data for HCC2- and HCCs>2 cm (HCC2+) to establish the treatment strategy for HCC2-. METHODS: Between April 2000 and December 2008, 206 patients with single HCC, who underwent hepatectomy for the first time, and whose outcomes could be tracked, were included in the study. There were 46 HCC2- and 160 HCC2+ patients. Survival and disease-free survival rates were compared between the two groups, in relation to various clinicopathological data. RESULTS: The 1-, 3-, and 5-year overall survival rates were 100%, 92.6%, and 72.8% for HCC2- and 93.3%, 72.4%, and 57% for HCC2+, respectively (P=0.0098). The 1, 3, and 5-year disease-free survival rates were 86%, 42.6%, and 31% for HCC2-, and 64.7%, 35.9%, and 12.5% for HCC2+, respectively (P=0.0642). Survival rates were better for HCC2- than for HCC2+ in terms of abnormal serum des-gamma-carboxy prothrombin, Child-Pugh Class A, single infection with HBV or HCV, and operative method used for anatomical resection, irrespective of ICG R15. Disease-free survival rates were better for HCC2- than for HCC2+ in terms of Child-Pugh Class A, and operative method used for anatomical resection. CONCLUSIONS: HCC2- has a better clinical outcome than HCC2+ after hepatic resection. Especially, HCC2- with an abnormal DCP value, Child-Pugh Class A, single infection with HBV or HCV, and anatomical resection, yields better outcomes. Even for HCC2- in patients with good liver function, anatomical resection is recommended.

Increased hepcidin production impairs iron metabolism after pancreatoduodenectomy.

BACKGROUND: The duodenum is a central organ for iron absorption. This study was performed to evaluate changes in body iron concentration and other iron-related molecules sequentially, in patients undergoing pancreatoduodenectomy (PD). METHODS: Twenty-one patients who had undergone PD at our department were enrolled in the study. Measurements of serum iron (sFe), total iron-binding capacity (TIBC), serum ferritin (sFer), C-reactive protein (CRP), interleukin-6 (IL-6), hemoglobin (Hb), hematocrit (Ht), and serum hepcidin (sHep) were performed before surgery (Pre), and on postoperative days 3 (D3), 7 (D7), and 14 (D14). RESULTS: The median values of sFe on Pre, D3, D7, and D14 were 73.0, 30.0, 33.0, and 41.0 microg/ dL, respectively (P < 0.05), and those of TIBC were 276.0, 160.0, 176.0, and 165.0 microg/ dL, respectively (P < 0.05). CRP and IL-6 became maximal on D3. The median values of sHep on Pre, D3, D7, and D14 were 18.9, 42.9, 25.7, and 21.2 mg/dL, respectively (P < 0.05). Hb and Ht reached minimum values on D3 and remained low until D14. The median values of sFer on Pre, D3, D7, and D14 were 135, 301, 267, and 233 ng/ dL, respectively. CONCLUSIONS: Hepcidin production is increased after pancreatoduodenectomy. Because hepcidin is known to divert iron to storage-type ferritin rather than to erythropoiesis, iron administration intended for erythropoiesis during this period may be ineffective.

The Glasgow Prognostic Score is a good predictor of treatment outcome in patients with unresectable pancreatic cancer.

BACKGROUND: We analyzed the outcome of patients with advanced unresectable pancreatic cancer treated in our department from 2001 to 2008. METHODS: Of the 83 patients included in this study, 50 patients received single-agent treatment with gemcitabine (GEM), 9 patients GEM combined with radiotherapy (GEM+R) and 24 patients had best supportive care (BSC). We analyzed survival rates among the groups and risk factors for each group. RESULTS: The 3-year survival rates were dismal: GEM group 2.9%, GEM+R group 0% and BSC group 0%. Significant prognostic factors of the study were: performance status (PS), response rate and decrease in the CA19-9 level. Significant prognostic factors by the Cox proportional hazard model were the albumin level prior to treatment, CA19-9 levels before treatment, decrease in CA19-9 and response rate. Albumin levels and the Glasgow Prognostic Score (GPS) were found to be factors affecting survival in the GEM group. CONCLUSION: In this series of patients with unresectable pancreatic cancer, good PS, decrease in CA19-9 after treatment and good GPS determined prior to treatment were independent prognostic factors for better overall survival.

Systemic inflammatory response predicts postoperative outcome in patients with liver metastases from colorectal cancer.

BACKGROUND: Few studies have investigated the Glasgow Prognostic Score (GPS) in patients with liver metastases from colorectal cancer (LM-CRC). METHODS: The GPS was calculated as follows: patients with both an elevated level of CRP (>10 mg/L) and hypoalbuminemia (Alb <35 g/L) were allocated a score of 2, and patients showing one or neither of these blood chemistry abnormalities were allocated a score of 1 or 0, respectively. RESULTS: Ninety-three patients were evaluated retrospectively. Kaplan-Meier analysis and log rank test revealed that a higher GPS predicted a higher postoperative death (P < 0.0001). Univariate analysis revealed that sex, number of hepatectomy, number of tumors, synchronous lung metastasis and CRP were associated with postoperative death. Multivariate analysis revealed that number of hepatectomy (odds ratio, 3.193; 95% CI, 1.093-9.330; P = 0.0338), number of tumors (odds ratio, 2.946; 95% CI, 1.094-7.931; P = 0.0325), synchronous lung metastasis (odds ratio, 3.424; 95% CI, 1.055-11.11; P = 0.0404) and CRP (odds ratio, 4.509; 95% CI, 1.313-15.49; P = 0.0167) were associated with postoperative death. CONCLUSIONS: GPS is able to classify patients with LM-CRC into three independent groups. Among the selected factors, CRP is considered an important and high sensitive predictor of postoperative death in such patients.

Pancreatic juice leakage is a risk factor for deep mycosis after pancreatic surgery.

PURPOSE: Deep mycosis (DM) is an opportunistic infection that can be fatal in immunocompromised hosts. Pancreatic surgery is associated with a high degree of stress and patients who undergo pancreatic surgery are considered to be immunocompromised. This study retrospectively evaluated whether DM affects the clinical course after pancreatic surgery. METHODS: Between January 2005 and April 2007, 67 patients underwent pancreatic surgery. There were 42 males (62.7%) and 25 females (37.3%) with a mean age of 66.7 years. Their diagnoses consisted of cancer of the papilla of Vater (n = 9), pancreatic head cancer (n = 20), pancreatic tail cancer (n = 3), bile duct cancer (n = 17), duodenal cancer (n = 3), and others (n = 15). Surgical procedures included pancreatoduodenectomies (PD; n = 52), hepato-pancreatoduodenectomies (HPD; n = 4), distal pancreatectomies (DP; n = 7), total pancreatectomies (TP; n = 2), and the modified Puestow procedure (m-Pp; n = 2). Patients who were positive for any of CAND-TEC (C-T), beta-D-glucan (beta-D), or culture for mycosis were classified into group 1 (G1; n = 12) and those who were negative for all these examinations were classified into group 2 (G2; n = 55). The preoperative, perioperative, and postoperative data were compared between G1 and G2. An antifungal drug (Micafungin; 75 mg per day) was given to G1 patients. RESULTS: The preoperative data included the neutrophil and lymphocyte counts, total protein, blood urea nitrogen, and amylase, and there were no significant differences in these parameters between the two groups. However, the incidences of diabetes mellitus and total bilirubin at maximum in G1 and G2 were 41.7% and 7.3% (P = 0.04), 4.6 +/- 1.5 and 1.4 +/- 0.9 (P = 0.007), respectively. The mean operation time in G1 and G2 was 548.5 +/- 138.1 and 510.0 +/- 133.7 min (P = 0.39) and intraoperative blood loss was 762.2 +/- 369.5 and 782.5 +/- 599.1 ml (P = 0.88), respectively. The postoperative complications included pneumonia (G1: G2 = 7: 20; P = 0.14), pleural effusion (7: 24; P = 0.27) and ascites (10: 33; P = 0.11), with no significant intergroup differences. However, the respective durations of pancreatic juice leakage in G1 and G2 were 12 and 12, respectively, with a statistically significant difference (P < 0.01). All the G1 patients were treated with the antifungal drug for 7.8 days. Postoperative hospital stays in G1 and G2 were 47.3 days and 38.7 days, respectively (P = 0.15) and the survival rates at 19 months after surgery were 46.7% and 79.4%, respectively (P = 0.04). CONCLUSIONS: Deep mycosis was observed in patients with pancreatic juice leakage, thus contributing to a poor outcome. Therefore, an early diagnosis of DM and the initiation of antifungal treatment are necessary for the improving prognosis.

Decreased expression of cytochromes P450 1A2, 2E1, and 3A4 and drug transporters Na+-taurocholate-cotransporting polypeptide, organic cation transporter 1, and organic anion-transporting peptide-C correlates with the progression of liver fibrosis in chronic hepatitis C patients.

Patients with chronic hepatitis C viral infection underwent liver biopsies and laboratory studies for evaluation and to determine subsequent treatment. Changes in status of drug metabolism and disposition may vary with chronic hepatitis C stage and should be assessed. Total RNA was extracted from liver biopsy specimens (n = 63) and reverse transcribed to yield cDNA. Relative mRNA levels of drug-metabolizing enzymes, transporters, nuclear receptors, and proinflammatory cytokines were analyzed with normalization to glyceraldehyde 3-phosphate dehydrogenase expression. mRNAs encoding cytochromes P450 1A2, 2E1, and 3A4, and drug transporters, Na(+)-taurocholate-cotransporting polypeptide, organic anion-transporting peptide-C, and organic cation transporter 1 showed remarkable decreases, and tumor necrosis factor-alpha showed an increase according to fibrosis stage progression. HepG2 cells and primary hepatocytes of two human individuals were treated with interleukin 1beta, interleukin 6, or tumor necrosis factor-alpha. CYP1A2 and Na(+)-taurocholate-cotransporting polypeptide mRNA levels significantly decreased in HepG2 cells with interleukin 1beta and interleukin 6 treatments. CYP2E1 and organic cation transporter 1 mRNA levels significantly decreased with tumor necrosis factor-alpha treatment only in HepG2. These results suggested that down-regulation of CYP1A2, 2E1, and 3A4, and drug transporters, Na(+)-taurocholate-cotransporting polypeptide, organic anion-transporting peptide-C, and organic cation transporter 1, manifested in livers of patients with chronic hepatitis C viral infection, was associated, at least in part, with the elevated production of proinflammatory cytokines, including tumor necrosis factor-alpha.

Xanthogranulomatous lesion of the pancreas mimicking pancreatic cancer.

BACKGROUND: Xanthogranulomatous lesion is a rare condition that can develop in the gall bladder, kidney, and retroperitoneal space. This lesion is an inflammatory disease. It is commonly accepted that Xanthogranulomatous lesion of the pancreas (XGP) is hardly distinguishable from pancreatic neoplasms. As a result of the similarity of pancreatic cancer in clinical and imaging diagnostic findings, most of all patients have often been performed excessive surgeries. CASE REPORT: An 82-year-old male was admitted to our hospital because of body weight loss. Laboratory tests showed the presence of inflammation, and a Positron emission tomography (PET) revealed positive uptake in the pancreas head and tail, and spleen. Duodeno scopy showed excretion of mucin from the papilla of Vater. Intraductal ultrasonography (IOUS) showed a tumor located at the pancreas tail. Under a preoperative diagnosis of intraductal papillary mucinous carcinoma (IPMC) at the pancreas tail with metastasis to the spleen, distal pancreatectomy and splenectomy were performed. Microscopic findings of the operative specimen revealed massive infiltration of macrophages with fibrosis, the lost of ductal epithelium, and the severe deposition of amyloid and mucin with thrombosis. Pathological diagnosis was XGP. The patient was uneventfully discharged from hospital on the postoperative day 22. Although XGP is a benign condition, most cases are treated by surgery same as our case. This is due to the difficulty in differenciating the lesion from pancreatic cancer. CONCLUSIONS: We reported a rare case of XGP mimicking pancreatic cancer. XGP should be added to one of differential diagnosis of pancreatic cancer.