Various types of reconstruction after pancreaticoduodenectomy for the patients who underwent all types of gastrectomy: a single-enter experience.

Purpose: The incidence of patients requiring pancreaticoduodenectomy (PD) following any type of gastrectomy is increasing as the population of elderly patients is increasing, especially in endemic areas of gastric cancer such as Korea. All types of gastrectomy can be categorized as subtotal gastrectomy with Billroth I (BI), Billroth II (BII), and total gastrectomy with Roux-en-Y anastomosis. In this paper, we reviewed our experiences of PD for patients who previously underwent gastrectomy. Methods: We reviewed the medical records of the patients who underwent PD following any type of gastrectomy among 505 consecutive patients who underwent PD in a single institution between 2011 and 2020 retrospectively. Results: There were 13 patients who had undergone gastrectomy including 7 patients of BI, 1 patient of BII, and 5 patients of total gastrectomy. For all 7 patients of BI, the reconstruction was not different from conventional PD. For the 1 patient of BII, previous gastrojejunal anastomosis was preserved and reconstruction was performed in Roux-en-Y method. For the 5 patients with total gastrectomy, 2 different types of reconstruction were performed. In one patient, we removed the remaining jejunum with the specimen, and reconstruction was performed. For the other 4 patients, the remaining jejunum, distal to the Treitz ligament, was preserved and was utilized for anastomosis. Surgeries for all patients were uneventful. Conclusion: PD following any type of gastrectomy can be safe. Especially, if the length of remained jejunum is long enough, its utilization for the reconstruction can be an appropriate option.

Unfavorable effect of high postoperative fluid balance on outcome of pancreaticoduodenectomy.

Purpose: Despite the many efforts to overcome postoperative complications, pancreaticoduodenectomy (PD) is still accompanied with considerable concerns of lethal complications. The clinical factors are known to affect postoperative outcomes such as diameter of pancreatic duct, texture of pancreas, and comorbidity of the patients are mostly uncorrectable. Thus, investigation for correctable risk factors is required. Recently, perioperative fluid volume was reported to be associated with complications after PD. This study aims to determine the relationship between postoperative fluid balance and surgical outcome after open PD. Methods: We reviewed, retrospectively, 172 consecutive patients who underwent open PD in a single institution between 2015 and 2019. The status of perioperative fluid balance 2 days after surgery and clinical factors were investigated to determine the association with postoperative outcome including postoperative pancreatic fistula (POPF). According to postoperative fluid balance, patients were divided into high- and low-balance groups, and clinical features and surgical outcomes were compared between both groups. Multivariate analysis were performed to identify risk factors for POPF. Results: The percentage of morbidity and the incidence of POPF were higher in the high-balance group compared to the low-balance group (61.6% vs. 37.2%, P = 0.001; 15.1% vs. 3.5%, P = 0.009). High postoperative fluid balance and the presence cardiovascular disease were correlated with POPF on multivariate analysis (odds ratio [OR], 4.574; 95% confidence interval [CI], 1.229-17.029; P = 0.023 and OR, 3.517; 95% CI, 1.209-12.017; P = 0.045). Conclusion: Higher amount of postoperative fluid balance and the presence of cardiovascular disease are associated with POPF after PD.

Double tract reconstruction versus double flap technique: short-term clinical outcomes after laparoscopic proximal gastrectomy for early gastric cancer.

BACKGROUND: Laparoscopic proximal gastrectomy (LPG) is increasingly preferred for operative management of early gastric cancer, although there is no consensus on a standard reconstruction method after resection. Two popular methods used after LPG are double tract reconstruction (DTR) and double flap technique (DFT). This study assessed comprehensive clinical outcomes including quality of life (QoL) and body composition change 1 year after DFT and DTR. METHODS: We retrospectively reviewed prospectively collected data from 51 to 18 patients who underwent DTR and DFT, respectively, between September 2014 and December 2018. Short-term surgical outcomes, presence of reflux esophagitis, nutritional supplementation, medications, nutritional status (laboratory results and body composition analysis), and QoL measured preoperatively and at 1 year postoperatively were compared between both groups. RESULTS: Both groups did not differ significantly in clinicopathological characteristics. The DFT as compared to the DTR group required significantly longer time for anastomosis (79.4 vs. 60.9 min, p < 0.001) and use of fewer staplers (3.39 vs. 6.86, p < 0.001). While the presence of endoscopic reflux esophagitis and iron/vitamin B12 replacement were comparable, the DTR group showed a higher tendency of taking anti-reflux medications for reflux symptoms (DTR: 13.7% vs. DFT: 0.0%, p = 0.177). The DTR group lost significantly more weight (p = 0.038) and body fat (p = 0.009). QoL analysis showed significant deterioration in diarrhea, eating restriction, and taste problems in both groups (DTR group: p = 0.008, p < 0.001, p = 0.010, respectively, and DFT group: p = 0.017, p = 0.024, p = 0.034, respectively). However, only the DTR group showed significant deterioration in physical function (p = 0.009), role function (p = 0.033), nausea/vomiting (p = 0.041), appetite loss (p = 0.019), dysphagia (p = 0.001), pain (p = 0.025), and body image (p = 0.004). CONCLUSIONS: Despite requiring a longer anastomosis time, performing DFT after LPG was shown to be an ideal reconstruction method in terms of better 1-year QoL and nutritional outcome. Further larger studies over longer postoperative periods are necessary to confirm our findings.

Malignant melanoma of the gallbladder: A case report and literature review.

Metastatic melanoma of the gallbladder is extremely rare. It has a poor prognosis. Its optimal treatment remains unclear. Surgical resection is generally considered the mainstay of treatment. However, there are no standards to guide the choice between open surgery and laparoscopic surgery. Criteria for the extent of surgical dissection have not been established yet either. We report a patient diagnosed with gallbladder cancer who underwent extended cholecystectomy but had metastatic melanoma at the final biopsy. We reviewed the literature on the treatment of metastatic melanoma in the gallbladder and compared it with our case to determine a treatment strategy.

Optimal surgical treatment in patients with T1b gallbladder cancer: An international multicenter study.

BACKGROUND: There is no consensus on the optimal treatment of T1b gallbladder cancer (GBC) due to the lack of evidence and the difficulty of anatomy and pathological standardization. METHODS: A total of 272 patients with T1b GBC who underwent surgical resection at 14 centers with specialized hepatobiliary-pancreatic surgeons and pathologists in Korea, Japan, Chile, and the United States were studied. Clinical outcomes including disease-specific survival (DSS) rates according to the types of surgery were analyzed. RESULTS: After excluding patients, the 237 qualifying patients consisted of 90 men and 147 women. Simple cholecystectomy (SC) was performed in 116 patients (48.9%) and extended cholecystectomy (EC) in 121 patients (51.1%). The overall 5-year DSS was 94.6%, and it was similar between SC and EC patients (93.7% vs. 95.5%, P = 0.496). The 5-year DSS was similar between SC and EC patients in America (82.3% vs. 100.0%, P = 0.249) as well as in Asia (98.6% vs. 95.2%, P = 0.690). The 5-year DSS also did not differ according to lymph node metastasis (P = 0.688) or tumor location (P = 0.474). CONCLUSIONS: SC showed similar clinical outcomes (including recurrence) and survival outcomes as EC; therefore, EC is not needed for the treatment of T1b GBC.

ERK1 Directly Interacts With JNK1 Leading to Regulation of JNK1/c-Jun Activity and Cell Transformation.

ERK1 and ERK2 share a great deal of homology and have been presumed to have similar functions. Available antibodies recognize both isoforms making the elucidation of functional differences challenging. Mitogen-activated protein (MAP) kinase networks are commonly depicted in the literature as linear and sequential phosphorylation cascades; however, the activation of these pathways is not mutually exclusive. Little doubt exists that MAP kinases engage in crosstalk, but the extent or the direct effect of these "conversations" is unclear. Here, we report the possible points of direct interaction as "crosstalk" points between ERK1 and JNK1 and a potential mechanism for ERK1 function in repressing Ras/JNK-mediated cell transformation. ERK1, but not ERK2, directly interacts with and antagonizes JNK1 phosphorylation and activity, resulting in suppression of neoplastic cell transformation mediated by the Ras/JNK/c-Jun signaling pathway. Interestingly, ERK1 phosphorylation was increased in normal tissues compared to liver cancer tissues. Furthermore, predominant JNK/c-Jun activation was observed in liver cancer tissues. These phenomena can provide evidence for the existence of a functional association between ERK and JNK signaling pathways during in vivo tumorigenesis. Overall, our findings provide new evidence supporting the paradigm of an ERK1/JNK1 antagonistic interaction as a novel mechanism of trans-regulation between different MAP kinase signaling modules. J. Cell. Biochem. 118: 2357-2370, 2017. © 2017 Wiley Periodicals, Inc.

Outcomes and recurrence pattern after non-anatomic liver resection for solitary hepatocellular carcinomas.

BACKGROUNDS/AIMS: Anatomic resection (AR) is preferred for eradicating portal tributaries in patients with hepatocellular carcinoma (HCC). However, the extent of resection is influenced by underlying liver disease and tumor location. We compared the surgical outcomes and recurrence pattern between non-anatomic resection (NR) and AR. METHODS: From March 2009 to February 2012, 184 patients underwent surgical resection for HCC. Among these, 79 patients who were primarily treated for a single tumor without rupture or macroscopic vascular invasion were enrolled. The patients were divided into 2 groups based on the extent of resection: AR (n=31) or NR (n=48). We compared the clinical characteristics, overall survival, disease-free survival, pattern of recurrence, and biochemical liver functions during the perioperative period between the two groups. RESULTS: The extent of resection had no significant effect on overall or disease-free survival rates. The overall 1- and 3-year survival rates were 97% and 82% in the AR group, and 96% and 89% in the NR group, respectively (p=0.49). In addition, the respective 1- and 3-year disease-free survival rates for the AR and NR groups were 84% and 63%, and 85% and 65%, respectively (p=0.94). On the other hand, the presence of hepatic cirrhosis and a tumor size of >5 cm were significant risk factors for recurrence according to multivariate analysis (p<0.001 and p=0.003, respectively). The frequency of early recurrence, the first site of recurrence, and the pattern of intrahepatic recurrence were similar between the 2 groups (p=0.419, p=0.210, and p=0.734, respectively); in addition, the frequency of marginal recurrence did not differ between the 2 groups (1 patient in the AR group and 2 in the NR group). The NR group showed better postoperative liver function than the AR group. CONCLUSIONS: Non-anatomic liver resection can be a safe and efficient treatment for patients with a solitary HCC without rupture or gross vascular invasion.

Prognostic factors in patients with middle and distal bile duct cancers.

AIM: To identify the influence of the surgery type and prognostic factors in middle and distal bile duct cancers. METHODS: Between August 1990 and June 2011, data regarding the clinicopathological factors of 194 patients with surgical and pathological confirmation were collected. A total of 133 patients underwent resections (R0, R1, R2; n = 102, 24, 7), whereas 61 patients underwent nonresectional surgery. Either pancreaticoduodenectomy (PD) or bile duct resection (BDR) was selected according to the sites of tumors and co-morbidities of the patients after confirming resection margin by the frozen histology in all cases. Univariate and multivariate analyses of clinicopathologic factors were performed, utilizing the Kaplan-Meyer method and Cox hazard regression analysis. RESULTS: The overall 5-year survival rate for the 133 patients who underwent resection (R0, R1, and R2) was 41.2%, whereas no patients survived longer than 3 years among the 61 patient who underwent nonresectional surgeries. The 5-year survival rate of the patients who underwent a PD (n = 90) was higher than the rate of those who underwent BDR (n = 43), although the difference was not statistically significant (46.6% vs 30.0% P = 0.105). However, PD had a higher rate of R0 resection than BDR (90.0% vs 48.8%, P < 0.0001). If R0 resection was achieved, PD and BDR showed similar survival rates (49.4% vs 46.5% P = 0.762). The 5-year survival rates of R0 and R1 resections were not significantly different (49.0% vs 21.0% P = 0.132), but R2 resections had lower survival (0%, P = 0.0001). Although positive lymph node, presence of perineural invasion, presence of lymphovascular invasion (LVI), 7th AJCC-UICC tumor node metastasis (TNM) stage, and involvement of resection margin were significant prognostic factors in univariate analysis, multivariate analysis identified only TNM stage and LVI as independent prognostic factors. CONCLUSION: PD had a greater likelihood of curative resection and R1 resection might have some positive impact. The TNM stage and LVI were independent prognostic factors.

Classifying extrahepatic bile duct metachronous carcinoma by de novo neoplasia site.

Extrahepatic bile duct (EHBD) cancer may occur metachronously, and these cancers are resectable with a favorable prognosis. We aimed to identify the pattern of metachronous EHBD cancer. We classified the cases of metachronous EHBD cancer reported in the literature thus far and investigated two new cases of metachronous EHBD cancer. A 70-year-old female underwent R0 bile duct resection for a type 1 Klatskin tumor (pT1N0M0). A 70-year-old male patient underwent R0 bile duct resection for a middle bile duct cancer (pT2N1M0). Imaging studies of both patients taken at 14 and 24 mo after first surgery respectively revealed a metachronous cholangiocarcinoma that required pancreaticoduodenectomy (PD). Histopathology of the both tumors after PD revealed cholangiocarcinoma invading the pancreas (pT3N0M0). Both patients have been free from recurrence for 6 years and 16 mo respectively after the second surgery. Through a review of the literature on these cases, we classified the pattern of metachronous EHBD cancer according to the site of de novo neoplasia. The proximal remnant bile duct was most commonly involved. Metachronous EHBD cancer should be distinguished from an unresectable recurrent tumor. Classifying metachronous EHBD cancer may be helpful in identifying rare metachronous tumors.

One Hundred Hepatectomies without Hospital Death under Intermittent Hepatic Inflow Clamping for 30 Minute Duration.

BACKGROUND/AIMS: Temporary clamping of the hepatic inflow is routinely applied to minimize haemorrhage during liver parenchyma. In this report, we describe successful intermittent application of the hepatic inflow for 30 minutes with zero hospital death in consecutive 100 hepatectomies. METHODOLOGY: One hundred consecutive patients undergoing elective liver resection were entered for this prospective study. A synthetic protease inhibitor (gabaxate mesilate, GM) was intravenously administrated continuously starting 12 hours before the operation until the second postoperative day. The patients underwent hepatectomy with a cycle consisting of intermittent application of inflow clamping for 30 minutes, followed by 5 minutes of declamping. Intraoprative data were evaluated together with complications and hospital death rates. Liver function tests were performed on postoperative days, 1, 3 and 7. RESULTS: All the patients discharged the hospital with a zero motality and an average hospital stay of 8 days postoperatively. Peak for aminotransferase were observed postoperative day 1 (382 ± 268, 245 ± 204 IU/L, mean ± SD for serum S-AST and S-ALT). The bilirubin and prothrombin times were normalized day 7 postsurgery. There were no differences between GM protocols. CONCLUSIONS: We have successfully confirmed that a cycle consisting of intermittent application of the hepatic inflow clamping yields safe hepatectomy under effective control of bleeding, when combined with use of a protease inhibitor.

Prognostic factors after early recurrence in patients who underwent curative resection for hepatocellular carcinoma.

BACKGROUND: The prognosis of the patients with early recurrence after curative hepatectomy for hepatocellular carcinoma (HCC) is usually dismal. METHODS: One hundred twenty-four patients underwent curative resection for HCC at Kyungpook National University Hospital from January 2002 to December 2006. An early recurrence was defined as a recurrence within 2 years after a curative resection. The risk factors associated with an early recurrence were analyzed as well as other risk factors correlated with survival after early recurrence. RESULTS: Early disease recurrence developed in 56 patients (45.2%). The risk factors associated with an early recurrence were a tumor size larger than 5 cm (P = 0.001) and the presence of tumor micrometastasis (P < 0.001). The 1 year/2 year overall survival, after early recurrence, was 57.0%/41.0% and the preoperative α-fetoprotein, C-reactive protein (CRP), tumor size, macroscopic vascular invasion, and number of tumors were associated with survival on the univariate analysis. The multivariate analysis showed that the independent risk factors for survival, after early disease recurrence, were a preoperative CRP >1.0 mg/dl and macroscopic vascular invasion. (P = 0.004, P < 0.001, respectively). CONCLUSION: The preoperative CRP and macroscopic vascular invasion were associated with the aggressiveness of early recurrent HCC.

Predictive factors for invasive intraductal papillary mucinous neoplasm of the pancreas.

BACKGROUNDS/AIMS: Intraductal papillary mucinous neoplasm (IPMN) of the pancreas has malignant potential. Predicting invasive IPMN has proven difficult and controversial. We tried to identify predictive factors for invasive IPMN. METHODS: Thirty six patients underwent resection for IPMN from February 2001 to July 2011. Clinicopathological features including demographic, imaging, microscopic, and serological findings were retrospectively reviewed. Receiver operating characteristic (ROC) curve analysis was used to analyze sensitivity and specificity of all possible cut-off values for the diameter of the main pancreatic duct and mass size predicting invasive IPMN. Student t-test, chi-square test, and logistic regression were used for univariate and multivariate analysis. RESULTS: The mean age was 63.5±8.4 years. Males were more commonly affected (58.3% vs 41.7%). Pancreaticoduodenectomy was performed in 55.6% of patients, distal pancreatectomy in 36.1%, and central pancreatic resection in 8.3%. Non-invasive IPMNs were present in 80.6% (n=29), whereas invasive IPMNs were present in 19.4% (n=7). In univariate analysis, tumor location (p=0.036), Kuroda classification (p=0.048), mural nodule (p=0.016), and main duct dilatation (≥8 mm) (p=0.006) were statistically significant variables. ROC curve analysis showed that a value of 8 mm for the main duct dilatation and a value of 35 mm for the size of the mass lesion have 80% sensitivity and 75% specificity and 100% sensitivity and 82.6% specificity, respectively. However, in multivariate analysis, main ductal dilatation (≥8 mm) was identified to be the only independent factor for invasive IPMN (p=0.049). CONCLUSIONS: Main duct dilatation appears to be a useful indicator for predicting invasive IPMN.

Prognostic factors for pulmonary metastasectomy in the treatment of hepatocellular carcinoma.

BACKGROUND: This study aimed to present our experience with pulmonary metastasectomy in the treatment of hepatocellular carcinoma and to evaluate the prognostic factors. METHODS: The clinicopathologic data of 17 patients including presence of viral hepatitis, the serum alpha-fetoprotein (AFP) level, the number of metastases, and laterality were analyzed. The overall survival rates and the prognostic factors were estimated using the Kaplan-Meier method and Cox proportional hazards model for multivariate analysis. RESULTS: The median follow-up periods after pulmonary resection and initial hepatic resection were 28.9 and 46.2 months, respectively. The actuarial overall 1-, 3-, and 5-year survival rates after pulmonary metastasectomy were 64.7 +/- 11.6%, 29.4 +/- 11.1%, and 11.8 +/- 7.8%, respectively. Using multivariate analysis, disease-free interval (DFI) of more than 24 months (hazard ratio = 2.36, 95% confidence interval = 1.33-25.33, p = 0.020) and AFP levels after pulmonary resection (hazard ratio = 51.3 95% confidence interval = 3.68-716.66, p = 0.003) were found to be independent prognostic factors. CONCLUSIONS: Although only a small number of patients were enrolled in this study, a disease-free interval more than 24 months and the serum AFP level after pulmonary metastasectomy might be important prognostic factors.

Chronic myeloid leukemia patient manifesting fatal hepatitis B virus reactivation during treatment with imatinib rescued by liver transplantation: case report and literature review.

Imatinib mesylate (imatinib) is now a standard treatment for patients with chronic myeloid leukemia (CML). Although imatinib is known to have a potential impact on various infectious organisms by altering the T-cell mediated immune response, only two cases of hepatitis B virus (HBV) reactivation during imatinib treatment have actually been reported. The role of liver transplantation (LT) after fatal HBV reactivation in patients with potentially treatable or curable hematologic malignancy is also unknown. Therefore, this report presents a case of fatal HBV reactivation during imatinib treatment for CML, where the patient is rescued by LT. Following a successful living donor LT, the liver function improves rapidly and the patient remains in complete cytogenetic remission after retreatment with imatinib for 6 months. The present report also covers the role of tyrosine kinase inhibitor in triggering HBV reactivation and a literature review of fulminant hepatic failure in CML patients taking imatinib.

Tetraspanin TM4SF5 mediates loss of contact inhibition through epithelial-mesenchymal transition in human hepatocarcinoma.

The growth of normal cells is arrested when they come in contact with each other, a process known as contact inhibition. Contact inhibition is lost during tumorigenesis, resulting in uncontrolled cell growth. Here, we investigated the role of the tetraspanin transmembrane 4 superfamily member 5 (TM4SF5) in contact inhibition and tumorigenesis. We found that TM4SF5 was overexpressed in human hepatocarcinoma tissue. TM4SF5 expression in clinical samples and in human hepatocellular carcinoma cell lines correlated with enhanced p27Kip1 expression and cytosolic stabilization as well as morphological elongation mediated by RhoA inactivation. These TM4SF5-mediated effects resulted in epithelial-mesenchymal transition (EMT) via loss of E-cadherin expression. The consequence of this was aberrant cell growth, as assessed by S-phase transition in confluent conditions, anchorage-independent growth, and tumor formation in nude mice. The TM4SF5-mediated effects were abolished by suppressing the expression of either TM4SF5 or cytosolic p27Kip1, as well as by reconstituting the expression of E-cadherin. Our observations have revealed a role for TM4SF5 in causing uncontrolled growth of human hepatocarcinoma cells through EMT.

Intrahepatic splenic tissue without medical history of splenic injury or splenectomy.

Only a few cases of intrahepatic splenic tissue have so far been reported in the English literature. Those cases were developed after splenic injury or a splenectomy. We report here a case of intrahepatic splenic tissue which has two distinctive features compared to previous literature. A 59-year-old female who previously had no medical history of splenic injury or splenectomy underwent hepatic resection for intrahepatic tumor mimicking hepatocellular carcinoma. However, pathologic examination revealed it as intrahepatic splenic tissue directly abutted to the normal liver tissue without a capsule. Lacking an invasive diagnostic modality, the diagnosis of intrahepatic splenic tissue without an accompanying medical history is very difficult.

Successful intermittent application of the Pringle maneuver for 30 minutes during human hepatectomy: a clinical randomized study with use of a protease inhibitor.

BACKGROUND/AIMS: There is experimental evidence that the liver can safely tolerate a cycle involving application of the Pringle maneuver for 30 minutes each time. METHODOLOGY: One hundred and twenty patients who underwent elective hepatectomy were randomly assigned to two groups of intermittent occlusion (30-min or 15-min Pringle group, n=60 each). A synthetic protease inhibitor (gabexate mesilate, GM, 2 mg/kg/h) was administered to pharmacologically alleviate visceral congestion, accompanied by hepatic pedicle clamping. Intraoperative data, liver function parameters and portal plasma levels of the inflammatory cytokine, interleukin (IL)-6 (a marker reflecting the status of visceral congestion), were examined as well as the postoperative course. Additionally, ten more patients randomly underwent right hepatectomy without GM, in order to clarify the influence of this agent on the present outcomes. RESULTS: The two groups of patients were comparable in terms of preoperative assessments, hepatic inflow occlusion time, extent of resection and background liver conditions. The 30-min Pringle group showed less blood loss during surgery (p=0.02) with a tendency for better postoperative mortality and morbidity. The postoperative liver functions were similar between the two groups. The portal plasma levels of IL-6 during pedicle clamping did not differ significantly between the two groups. When GM was not used, the 30-min intermittent Pringle maneuver induced a two-fold rise in serum transaminase levels on day 1 compared with the 15-min group. CONCLUSIONS: Our study indicates that intermittent application of the Pringle maneuver for 30 minutes each time can be accomplished effectively and safely for human hepatectomy, when combined with use of a protease inhibitor.

Evaluation of a protease inhibitor in the prevention of ischemia and reperfusion injury in hepatectomy under intermittent Pringle maneuver.

BACKGROUND: The severity of ischemia and reperfusion (I/R) injury is an important determinant of patient outcome in hepatic surgery. The aim of this study was to investigate the efficacy of a protease inhibitor in alleviating I/R injury to human liver in the setting of hepatectomy under intermittent Pringle maneuver. METHODS: Sixty patients who underwent liver resection under conditions of intermittent inflow occlusion were randomly assigned to 2 groups (n = 30 each) according to the use of a synthetic protease inhibitor (gabexate mesilate or GM). GM was administered intravenously at a dosage of 2.0 mg/kg/h starting 12 hours before surgery until postoperative day 2. Preoperative and intraoperative clinical variables and postoperative outcomes were evaluated. The plasma levels of a cytokine, interleukin (IL)-6, as well as laboratory biochemical liver function parameters were analyzed to evaluate hepatic I/R injury. RESULTS: The 2 groups of patients were comparable with regard to hepatic inflow occlusion time, extent of liver resection, and background liver histology. The preoperative administration of GM (GM group) substantially alleviated hepatic I/R injury compared with the untreated control group; postoperative serum transaminase levels were significantly decreased in association with marked suppression of IL-6 levels in blood circulation during surgery. This was accompanied by a lower incidence of postoperative complications. The patients without postoperative complications had significantly lower activities of plasma IL-6 at 24 hours after surgery. CONCLUSIONS: This prospective randomized study demonstrated the hepatoprotective effect of a synthetic protease inhibitor in the setting of hepatectomy under the intermittent Pringle maneuver.

[The comparative results of radiofrequency ablation versus surgical resection for the treatment of hepatocellular carcinoma].

BACKGROUND/AIMS: Although surgical resection remains the gold standard of therapy for hepatocellular carcinoma (HCC), only selected patients can undergo resection because of the severity of the underlying cirrhosis or due to the diffuse distribution of the tumor. Radiofrequency ablation (RFA) has recently shown comparable results to surgical resection for the treatment of HCC. We compared the results of RF ablation and surgical resection for the treatment of HCC. METHODS: From January 2000 to December 2002, one hundred-sixty patients who had undergone surgical resection or RFA were analyzed retrospectively. The patients with a tumor size less than 5 cm in diameter, with less than 3 tumors in number, with tumor having a Child-Pugh class A classification and no evidence of extrahepatic metastasis were enrolled in the study. The recurrence pattern was classified into local and distant recurrence. We compared the recurrence patterns, the survival rates, the recurrence rates and the complications between the two groups. RESULTS: 1) The local recurrence rate was 9.8% for surgical resection and 18.2% for RFA and the distant recurrence rate were 32.8% and 28.3%, respectively. 2) The 1-, 2- and 3-year overall cumulative survival rates after RFA and surgery were 95.8%, 86.8%, 80.0%, 98.3%, 87.0% and 77.4%, respectively. 3) The incidence of complication was similar between the two groups. CONCLUSIONS: Radiofrequency ablation shows comparable results to surgical resection for the treatment of HCC. Therefore, RFA should be considered as the treatment of choice those patients who are not candidates for resection. However, intrahepatic recurrence of tumor after RFA was as frequent as that seen after surgical resection. Further investigation is warranted to clarify whether the current RFA technology could offer improved long-term results.

Lethal hypercytokinemia following hepatic resection under pringle maneuver: a case report.

Clinical implications of acute reactant cytokines remain to be clarified in ischemia/reperfusion injury of humans. We report a lethal case of hypercytokinemia following continuous Pringle maneuver. A 36-year-old man with intrahepatic duct stones underwent left lobectomy under continuous hepatic inflow occlusion for 70 minutes. The postoperative course was stormy with rapid deterioration of liver functions, resulting in death due to multiorgan dysfunction on the 4th postoperative day. Analysis of cytokines demonstrated marked elevation of plasma acute inflammatory cytokines level (Interleukin-6 and -8) during surgery and immediate postoperative day. Our experience suggests that excessive production of inflammatory cytokines was detrimentally associated with multiorgan dysfunction including liver. The strategies against such hypercytokinemia should be considered when performing liver resection particularly under continuous Pringle maneuver.