Detection of Portal Vein Stenosis by Technetium-99m-Diethylenetriaminepentaacetic Acid-Galactosyl Human Serum Albumin Liver Scintigraphy after Living-Donor Liver Transplantation.

BACKGROUND/AIM: To investigate portal vein stenosis after living-donor liver transplantation by liver scintigraphy. METHODOLOGY: A 63-year-old woman with hepatic cirrhosis due to autoimmune hepatitis underwent living-donor liver transplantation using a graft donated by her daughter. Technetium-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin (Tc-99m-GSA) scintigraphy was used to determine the maximum rate of Tc-99m-GSA removal (GSA-Rmax) by hepatocytes, as a parameter of hepatic functional reserve. RESULTS: Conventional liver function parameters on laboratory tests and graft volume on computed tomography (CT) were almost unchanged at postoperative month (POM) 12. GSA-Rmax was 0.11 mg/min before surgery and increased 5-fold to approximately 0.5 mg/min at POM 1 and 3, followed by a decrease to 0.25 mg/min at POM 6 and 12. Enhanced CT did not detect blood flow in the intra- or extrahepatic portions of the portal vein at POM 12. The portal vein stenosis was dilated with a balloon catheter, followed by deployment of a self-expanding stent across the stenotic segment via the transileocolic vein. GSA-Rmax recovered to 0.5 mg/min at POM 15, and subsequently remained high. CONCLUSIONS: Decreased GSA-Rmax at POM 6 indicated that the portal vein stenosis was affecting graft function. Tc-99m-GSA liver scintigraphy may be a useful noninvasive method for evaluation of graft functional reserve.

Preoperative regional maximal removal rate of technetium-99m-galactosyl human serum albumin (GSA-Rmax) is useful for judging the safety of hepatic resection.

BACKGROUND: For hepatic resection, the preoperative estimation of hepatic functional reserve in the predicted remnant liver may be more important than that of the entire liver. We evaluated the maximal removal rate of technetium-99m-galactosyl-human serum albumin (GSA-Rmax) in the remnant. METHODS: One hundred and seventy-eight patients were admitted for elective hepatectomy. Conventional liver function, and 15-minute retention rate of indocyanine green (ICGR15) were carried out preoperatively. The GSA-Rmax was calculated according to a radiopharmacokinetic model; then we used the single photon emission computed tomography images to calculate the regional GSA-Rmax in the predicted residual liver (GSA-RL), depending on the operative procedures. The volume of the predicted residual liver (LV-RL) was calculated on the basis of computed tomography images. RESULTS: The preoperative LV-RL correlated well with the GSA-RL in patients with normal liver; however, there was no such correlation in those with chronic hepatitis or cirrhosis. All of 7 postoperative hyperbilirubinemia occurred in the patients with GSA-RL < 0.15. Two patients died of postoperative liver failure 1 to 2 months after the operation. These 2 patients had GSA-RL values of 0.078 and 0.090, respectively, and severe discrepancies between the GSA-Rmax in the remnant liver and ICGR15. CONCLUSIONS: We concluded that GSA-RL may be useful for determining the procedure of hepatectomy and that the value should be maintained at greater than 0.15 to avoid postoperative hyperbilirubinemia or hepatic failure.

Acupuncture-induced cerebral blood flow responses in dystonia.

OBJECTIVE: The effect of acupuncture (ACP) on regional cerebral blood flow (rCBF) is unclear. Single-photon emission computed tomography studies on three patients with dystonia were performed before and after ACP treatment to test the contention that ACP affects rCBF. METHODS: Pre-ACP and post-ACP CBF study were performed on the same day; 99mTc ethyl cysteinate dimer was injected for each study. rCBF images were analyzed using a three-dimensional stereotaxic ROI template (3DSRT) to objectively measure rCBF. We evaluated rCBF bilaterally in five segments related to the pathophysiology of dystonia (1, superior frontal; 2, middle and inferior frontal; 3, primary sensorimotor; 4, lenticular nucleus; and 5, thalamus). More than 10% left-right asymmetry in rCBF over three continuous slices was defined as significant laterality. Post-ACP rCBF and laterality were evaluated with the pre-ACP rCBF study acting as a control in each subject. RESULTS: The clinical effect of ACP was remarkable in all patients and rCBF increased in most segments. Pre-ACP rCBF exhibited significant laterality in eight segments of the three patients. Laterality reversed in seven of these segments and resolved in the remaining segment after ACP. Pre-ACP rCBF laterality was not preserved in any segment after ACP. The remaining five segments exhibited laterality only after ACP. In total, after ACP, 13 of 15 segments demonstrated a change in CBF that was greater unilaterally. CONCLUSIONS: ACP results in an increase in CBF that is greater unilaterally. We think that unilateral change in CBF may be correlated with the action of ACP on the central nervous system in patients with dystonia.

Characterization of the asialoglycoprotein receptor under hypoxic conditions in primary cultured rat hepatocytes.

UNLABELLED: Hepatic ischemia/reperfusion injury occurs in numerous clinical situations including liver transplantation and hepatic resection. Therefore, accurate functional assessment of hepatocytes and prevention of ischemia/reperfusion injury to hepatocytes would be important. (99m)Tc-Galactosyl-human serum albumin is a liver scintigraphic agent that binds to asialoglycoprotein receptors (ASGP-R) on hepatocytes. We determined the number of ASGP-R during hypoxic conditions in primary cultured rat hepatocytes. METHODS: We used 3 durations of hypoxia (1, 2, and 3 h) for the cultured rat hepatocytes. The control incubation was performed under normoxic conditions (humidified 5% CO(2) in air) for the entire experiment. The maximal binding of (99m)Tc-galactosyl-human serum albumin (Bmax) to the hepatocytes (plasma membrane and endocytosis) and ketone body ratio (KBR) in the medium were estimated. RESULTS: The Bmax to hepatocytes and the KBR significantly decreased with time under the 3 different hypoxic conditions, whereas the cell counts of the hepatocytes did not decrease. Three hours after reoxygenation, the Bmax and KBR values that were decreased in the first 2 h of hypoxia reversed to control levels, but those Bmax and KBR values that were decreased after 3 h of hypoxia were irreversible. CONCLUSION: We conclude that the decrease in the number of ASGP-R per hepatocyte appears to be more significant than the decrease in the number of hepatocytes. Therefore, measurement of ASGP-R may provide an accurate assessment of hepatic function in the clinical setting of hepatic injury and recovery.

Impact of injected dose and acquisition time on a normal database by use of 3D-SSP in SPECT images: quantitative simulation studies.

The present study aimed to validate the accuracy of normal databases (NDBs) with respect to variable injected doses and acquisition times by use of three-dimensional stereotactic surface projections (3D-SSP) in N-isopropyl-p-[123I]-iodoamphetamine (I-123-IMP) brain perfusion images. We constructed NDBs based on brain SPECT images obtained from 29 healthy volunteers. Each NDB was rebuilt under simulated unique conditions by use of dynamic acquisition datasets and comprised injected doses (222, 167, and 111 MBq) and acquisition times (30, 20, and 15 min). We selected seven of 29 datasets derived from the volunteers to simulate patients' data (PD). The simulated PD were designed to include regions of hypoperfusion. The study comprised protocol A (same conditions for PD and NDB) and protocol B (mismatched conditions for PD and NDB). We used 3D-SSP to compare with the Z score and detection error. The average Z scores were decreased significantly in protocol A [PD (High)-NDB (High) vs. PD (Low)-NDB (Low); PD (30 m)-NDB (30 m) vs. PD (15 m)-NDB (15 m) and PD (20 m)-NDB (20 m)].The average Z scores of PD (High) and PD (Medium) with NDB (High) did not differ significantly in protocol B, whereas all others were decreased significantly. The error of detection increased 6.65 % (protocol A) and 32.05 % (protocol B). The Z scores were specific to the injected dose and acquisition time used in 3D-SSP studies, and the calculated Z scores were affected by mismatched injected doses and acquisition times between PD and selected NDBs.

Dietary restriction: effects of short-term fasting on protein uptake and cell death/proliferation in the rat liver.

Dietary restriction (DR) is known to prolong life in laboratory animals. Intermittent (alternate-day) fasting or short-term repeated fasting has also been reported to increase the life span of animals. In the present study, we investigated the changes or induction of abnormalities of protein metabolism in rats during fasting, and measured asialoglycoprotein uptake and cell death/proliferation in the liver of rats receiving fasting and refeeding. In the results, liver weight decreased significantly after 48 h of fasting and increased during the refeeding period, returning to the pre-fasting level by 12 h of refeeding. Cell death, determined by single stranded DNA (ssDNA) staining method, increased during the fasting period, and returned to the pre-fasting level during the refeeding period. Cell proliferation, determined using antibodies (Ab) against proliferating cell nuclear antigen, decreased during the fasting period, and increased during the refeeding period. Changes in cell death and cell proliferation were inversely related. However, there was no significant difference in asialoglycoprotein uptake by the whole liver between the ad libitum (AL)-fed rats and 48 h fasted rats. Thus, neither the changes in liver weight nor cell death/proliferation affected asialoglycoprotein uptake on a living body. These results suggest that episodes of 48 h fasting do not induce protein metabolism abnormalities in the liver.

Magnetic resonance determination of tumor thickness as predictive factor of cervical metastasis in oral tongue carcinoma.

OBJECTIVES: To establish an accurate and reproducible means of measuring tumor thickness as a preoperative prognostic factor for cervical metastasis in oral tongue carcinoma. STUDY DESIGN: Retrospective review. METHODS: Charts from 30 patients were reviewed, and the correlation between histopathological and magnetic resonance imaging (MRI) findings of actual tumor thickness or reconstructed tumor thickness measured between a reconstructed mucosal line and the deepest extent of the tumor was investigated. Magnetic resonance images were acquired on a 1.5 T-scanner with a T2-weighted sequence in the axial plane using 3-mm-thick sections and a 256 x 256 matrix. The correlation between N stage and tumor thickness acquired by histopathological scrutiny or MRI was also assessed. RESULTS: The correlation between histopathological and MRI examinations was more significant in terms of reconstructed than actual tumor thickness. No cervical metastasis was detected in patients with tumors of less than 6 mm of reconstructed thickness in the MRI examination. The difference in cervical metastasis between the two groups, namely, less than 6 or more than 6 mm, was statistically significant (P = .0051). CONCLUSIONS: Magnetic resonance imaging examination provides useful data for prognostic assessment and planning strategies with which to treat oral tongue carcinoma. The preoperative decision as to whether to attempt neck dissection could be based on a tumor thickness of 6 mm for patients with oral tongue carcinoma.

An unusual arterial supply of the kidney from the opposite renal artery.

We describe an extremely rare case with a supplementary artery arising from an opposite renal artery without renal anomalies in position and in form. An unusual artery crossing the aorta can be suggested by contrast-enhanced computed tomography. A renal cell carcinoma is supplied by the branch of the opposite renal artery.

[Availability of normal database by single photon emission computed tomography system with use of 3 dimensional-stereotactic surface projections].

PURPOSE: The present study aims to quantitatively investigate a normal database (NDB) created under the same acquisition and reconstruction conditions for three gamma camera systems (four types of collimator systems) with use of three-dimensional stereotactic surface projections (3D-SSP). We rebuilt a NDB with use of the N-isopropyl-p-(123)I-iodoamphetamine ((123)I-IMP) SPECT data derived from 30 healthy individuals at 20 institutions nationwide. We standardized the acquisition and reconstruction conditions, evaluated Z scores using patient data (PD) and examined each compensation effect. RESULTS: Z scores determined using the advanced NDB were the same value. Artifacts were often generated in Z score maps derived from the conventional NDB (CONDB). The Z score of the own site NDB (OWNDB) was 70% of that calculated based on the CONDB. The combinatorial difference in compensation (scatter and attenuation) resulted in many artifacts being generated in Z score map images. DISCUSSIONS: More artifacts were generated in Z score map images using the novel NDB compared with the CONDB. The novel NDB was comparable to the performance of OWNB. The accuracy of brain function image analysis can be improved the reconstruction conditions and correcting for scatter and attenuation on both the novel NDB and PD.

Effects of late evening snack including branched-chain amino acid on the function of hepatic parenchymal cells in patients with liver cirrhosis.

AIM: A late evening snack (LES) improves protein-energy malnutrition due to overnight starvation and the catabolic state in patients with liver cirrhosis. Our aim was to examine whether LES including a branched-chain amino acid (BCAA) could maintain hepatic reserve and the function of hepatic parenchymal cells in patients with liver cirrhosis, including those in the early stage of disease. METHODS: Seventeen patients with liver cirrhosis received LES with a BCAA-enriched nutrient mixture. During the study period, each patient was instructed on energy and protein intake. Indicators of liver function measured at 6 months included maximum asialoscintigraphic removal (Rmax: indicator of total liver receptors), asialoscintigraphic imaging grade, serum albumin, ammonia, tyrosine and BTR (molar ratio of branched-chain amino acids to tyrosine). RESULTS: Serum albumin levels, BTR and tyrosine levels of the 17 patients were significantly improved after nutrient treatment. In patients with Rmax of 0.2 or higher, serum albumin level and tyrosine level were significantly improved. CONCLUSION: LES with BCAA-enriched nutrient therapy can improve protein malnutrition in patients with liver cirrhosis, and is more useful in the early stages of liver cirrhosis in improving hepatic parenchymal cell mass.

Usefulness of Tc-99m-GSA scintigraphy for liver surgery.

Postoperative mortality remains high after hepatectomy compared with other types of surgery in patients who have cirrhosis or chronic hepatitis. Although there are several useful perioperative indicators of liver dysfunction, no standard markers are available to predict postoperative liver failure in patients with hepatocellular carcinoma (HCC) undergoing hepatectomy. The best preoperative method for evaluating the hepatic functional reserve of patients with HCC remains unclear, but technetium-99m diethylenetriamine pentaacetic acid galactosyl human serum albumin ((99m)Tc-GSA) scintigraphy is a candidate. (99m)Tc-GSA is a liver scintigraphy agent that binds to the asialoglycoprotein receptor, and can be used to assess the functional hepatocyte mass and thus determine the hepatic functional reserve in various physiological and pathological states. The maximum removal rate of (99m) Tc-GSA (GSA-Rmax) calculated by using a radiopharmacokinetic model is correlated with the severity of liver disease. There is also a significant difference of GSA-Rmax between patients with chronic hepatitis and persons with normal liver function. Regeneration of the remnant liver and recurrence of hepatitis C virus infection in the donor organ after living donor liver transplantation have also been investigated by (99m)Tc-GSA scintigraphy. This review discusses the usefulness of (99m)Tc-GSA scintigraphy for liver surgery.

Percutaneous translumbar inferior vena cava cannulation under computed tomography guidance.

Percutaneous translumbar inferior vena cava (IVC) cannulation is an alternative approach for central venous catheterization, but there have been sporadic reports of puncture-related complications. To avoid complications during IVC puncture, percutaneous translumbar IVC cannulation was performed under computed tomography (CT) guidance in addition to fluoroscopy in two patients. To perform chemotherapy for recurrent breast cancer, we planned subcutaneous port catheter placement for central venous access. Under CT guidance, the direction and insertion distance of a long elastor needle were adjusted, and the IVC was punctured at the level of the third lumbar vertebra while taking care to avoid the right urinary tract. A guidewire was inserted through the long elastor needle, and a catheter was placed over the guidewire. It was possible to perform central venous catheterization by percutaneous translumbar inferior vena cava cannulation under CT guidance.

HA/GSA-Rmax ratio as a predictor of postoperative liver failure.

BACKGROUND: Postoperative mortality after hepatectomy remains high compared with other types of surgery in patients who have cirrhosis or chronic hepatitis. Although there are several useful perioperative markers of liver dysfunction, there are no standard markers for predicting postoperative liver failure. This study investigated risk factors for postoperative liver failure after resection of hepatocellular carcinoma to detect markers that could identify candidates for hepatectomy. METHODS: Perioperative risk factors for liver failure after hepatectomy were analyzed in 191 patients with hepatocellular carcinoma. Multivariate logistic regression analysis was done to investigate factors with a significant independent influence among 35 variables. The ratio of serum hyaluronic acid to the maximum removal rate of technetium-99 m diethylenetriaminepentaacetic acid galactosyl human serum albumin (hyaluronate/GSA-Rmax ratio) was calculated. RESULTS: Liver failure occurred postoperatively in 16 patients, 3 of whom died. The hyaluronate/GSA-Rmax ratio was a risk factor for postoperative liver failure by univariate analysis and was the only risk factor according to multivariate analysis. All three patients who died had a hyaluronic acid/GSA-Rmax ratio > or = 500 mg min/dl. This ratio had a sensitivity of 88% and a specificity of 92% for predicting liver failure. CONCLUSIONS: To reduce postoperative liver failure, preoperative planning should employ various measures of the hepatic functional reserve, including tests of both parenchymal and nonparenchymal liver function. The hyaluronate/GSA-Rmax ratio can predict liver failure after hepatectomy, and a ratio > or = 500 mg min/dl is a relative contraindication to liver resection.

Liver regeneration in donors evaluated by Tc-99m-GSA scintigraphy after living donor liver transplantation.

The impact of hepatic steatosis on regeneration of the remnant liver after living donor liver transplantation is unclear. We evaluated the impact of steatosis on regeneration and function of the remnant liver by using technetium-99m-diethylenetriaminepentaacetic acid-galactosyl human serum albumin scintigraphy. Twelve living donors were classified into groups with or without mild hepatic steatosis according to the liver-to-spleen attenuation ratio on computed tomography: 6 donors had a ratio >or= 1.20 (control group) and 6 donors had a ratio < 1.20 (fatty liver group). Scintigraphy was performed to determine the hepatic uptake ratio of the tracer (corrected for disappearance from the blood) and the maximum removal rate of the tracer by hepatocytes as parameters of the hepatic functional reserve. The fatty liver group had a significantly lower corrected hepatic uptake ratio and removal rate compared with the control group at 6 and 12 months after partial hepatectomy. These parameters were decreased at 1 month after surgery in both groups. However, both parameters returned more rapidly to prehepatectomy levels in the control group. The regenerated liver volume estimated by scintigraphy did not differ significantly between the two groups at any time. Liver scintigraphy may be useful for evaluating the regeneration of functioning hepatocytes. Because donors with mild hepatic steatosis showed impaired liver regeneration at 1 year after partial hepatectomy, management of these donors requires more care.

Recurrent hepatitis C after living donor liver transplantation detected by Tc-99m GSA liver scintigraphy.

Recurrence of hepatitis C virus (HCV) after living donor liver transplantation was investigated using technetium-99m- diethylenetriaminepentaacetic acid-galactosyl human serum albumin (Tc-99m-GSA) liver scintigraphy. Four patients with decompensated cirrhosis due to HCV infection were retrospectively reviewed in this study. Scintigraphy was performed to determine the hepatic uptake ratio of the tracer corrected for disappearance from the blood, as well as the maximal removal rate of the tracer by hepatocytes, as parameters of hepatic functional reserve. In all patients, serum HCV ribonucleic acid (RNA) was detected 3 months after transplantation. The corrected hepatic uptake ratio and removal rate showed little change after transplantation in two patients without the recurrence of HCV infection. In another two patients, these levels were decreased at 3 months after transplantation. In one patient, recurrent HCV infection was diagnosed by confirmatory histologic examination at 12 months after transplantation. In the other patient, both levels declined further at 8 months. Although treatment was initiated with a combination of interferon plus ribavirin, this patient died of progressive hepatic failure. In conclusion, a decrease in scintigraphic parameters at 3 months after transplantation suggests recurrent HCV infection affecting the graft. Tc-99m-GSA liver scintigraphy is a useful noninvasive method for evaluating graft functional reserve.