Risk factors for major morbidity after liver resection for hepatocellular carcinoma.

BACKGROUND: Bile leakage, and organ and/or space surgical-site infection (SSI) are common causes of major morbidity after partial hepatectomy for hepatocellular carcinoma (HCC). The purpose of this study was to analyse risk factors for major morbidity and to explore strategies for its reduction after partial hepatectomy for HCC. METHODS: Risk factors for bile leakage and organ/space SSI were analysed in patients who underwent partial hepatectomy for HCC between 2001 and 2010. The causes, management and outcomes of intractable bile leakage requiring endoscopic therapy or percutaneous transhepatic biliary drainage were analysed. In addition, causative bacteria, outcomes and characteristics of organ/space SSI were investigated. Risk factors were identified using multivariable analysis. RESULTS: Some 359 patients were included in the analysis. The prevalence of bile leakage and organ/space SSI was 12·8 and 8·6 per cent respectively. Repeat hepatectomy and an operating time of at least 300 min were identified as independent risk factors for bile leakage. The main causes of intractable bile leakage were latent strictures of the biliary system caused by previous treatments for HCC and intraoperative injury of the hepatic duct during repeat hepatectomy. Independent risk factors for organ/space SSI were repeat hepatectomy and bile leakage. Methicillin-resistant Staphylococcus aureus was detected more frequently in organ/space SSI after repeat hepatectomy than after initial partial hepatectomy. CONCLUSION: Repeat hepatectomy and prolonged surgery were identified as risk factors for bile leakage after liver resection for HCC. Bile leakage and repeat hepatectomy increased the risk of organ/space SSI.

Refractory response to growth factors impairs liver regeneration after hepatectomy in patients with viral hepatitis.

BACKGROUND/AIMS: Liver regeneration after surgical resection is important. The present study was designed to understand the effect of background liver damage on the rate of liver tissue regeneration after hepatectomy and the mechanism of any defective regeneration. METHODOLOGY: The subjects were 40 patients who underwent liver resection. They comprised 22 patients with chronic viral hepatitis-hepatocellular carcinoma (liver damage group) and 18 patients with hepatic metastases from colorectal cancer (normal liver group). Liver regeneration was evaluated by histopathological and immunohistochemical examination of the surgically resected tissue and by CT-scanning of the regenerated liver mass. The resected liver specimens were stained for c-met, gp-130 and nuclear factor-kappaB (NF-kappaB) proteins. RESULTS: Liver regeneration was significantly less in the liver-damage group than in the normal-liver group. Histopathological examination showed marked inflammatory cell infiltration in the liver-damage group. Expression of c-met, but not gp-130, was significantly higher on parenchymal cells of the liver-damage group than the normal-liver group. NF-kappaB expression in parenchymal liver cells was significantly higher than in non-parenchymal cells of the normal-liver group. In the liver-damage group, liver regeneration correlated negatively with the staining intensity of NF-kappaB protein in non-parenchymal cells. These findings suggest that non-parenchymal cells are constitutively activated in the damaged liver, probably explaining the refractoriness of hepatocytes to cytokine-induced proliferation after hepatectomy, in spite of increased receptor (c-met) expression. CONCLUSIONS: The refractory response of injured hepatocytes to cytokines may explain the impaired postoperative liver regeneration in patients with damaged liver.

The effects of nutritional repletion on donors for liver transplantation in pigs.

It has been shown that the nutritional state of the donor may affect the outcome of liver transplantation. However, many donors staying in the intensive care unit for a long period are in a reduced nutritional state. In this study, we investigated the effects of various methods of nutritional repletion on the outcome of liver transplantation in pigs. Donor pigs were divided into three groups according to the nutritional pretreatment given for 7 days before harvesting: group I were fasted and received intravenous administration of saline; group II were fed orally; group III were fasted, but given 20% glucose intravenously. Donor livers were stored for 4 hr in cold Euro-Collins' solution and transplanted. The serum AST level 24 hr after reperfusion remained at a lower level in group III compared with those in groups I and II. Bile production of the liver after transplantation was also well recovered in group III. The glycogen content of the liver at harvesting, which was completely consumed in group 1, was well preserved in groups II and III. These storages in both groups were rapidly consumed 1 hr after reperfusion. On the other hand, ATP content of the liver in groups I, II, and III, which were at a similar level at harvesting, were markedly decreased 4 hr after cold preservation and, 1 hr after reperfusion, recovered to 26%, 48%, and 73% of that before preservation, respectively. The mean survival time in group III was 37.2 days, significantly longer than 5.8 +/- 0.7 and 9.8 +/- 2.0 days in groups I and II, respectively (P < 0.01). These results show that the favorable outcome of liver transplantation depends on the glycogen storage in the donor liver, and also on ATP generation after reperfusion. Furthermore, it was suggested that ATP generation was affected by some unknown factor related to the method of nutritional repletion.

Successfully resected hepatoblastoma in a young adult with chronic hepatitis B: report of a case.

Hepatoblastoma usually occurs in children, but a few cases have also been reported in adults. We report the unusual case of hepatoblastoma in an 18-year-old adult with chronic hepatitis B. He visited a local hospital with right upper abdominal pain. Abdominal ultrasound showed a large mass in the right lobe of his liver. He was referred to our hospital and admitted for further examination. At admission, liver function tests gave slightly elevated results (aspartate aminotransferase (AST) 103 IU/l, alanine aminotransferase (ALT) 63 IU/l). A test for hepatitis virus revealed that he was a hepatitis B surface antigen (HBsAg) carrier and had experienced seroconversion. His alpha-fetoprotein (AFP) was elevated to 1 548 000 IU/ml. Abdominal ultrasound showed a 109 x 96 x 80-mm mass with mosaic pattern in the right lobe of the liver and right portal vein thrombus. Abdominal computed tomography (CT) demonstrated a large low-density mass occupying the right lobe, with some high-density parts that showed calcification. From these results, we diagnosed hepatoblastoma in a young adult. A right lobectomy was performed. Pathological examination showed a highly differentiated hepatoblastoma. Adjuvant chemotherapy was performed with cisplatin and pirarubicin. The patient has been well and free of recurrence for 12 months, and his AFP level remains almost normal.

The effect of nitric oxide production by sinusoidal endothelial cells on preservation injury during cold ischemia.

Multifactorial elements are responsible for preservation and reperfusion injury in liver allografts. Sinusoidal endothelial cells (SECs) are a primary target of cold preservation injury of the liver. We examined the correlation between nitric oxide (NO) production by SECs and their injury during cold preservation. SECs were isolated from rat livers and preserved in either Euro-Collins (EC) or University of Wisconsin (UW) solution. Injury to the SECs was more severe when preserved in the EC solution than in the UW solution during cold ischemia. In addition, NO production by SECs was found to be proportionate to the cell injury. Cell viability was not improved by the addition of NO inhibitor, L-NMMA. Further, NO inhibitor was detrimental to the SECs in a 24-h preservation in UW solution. LDH release by SECs preserved in UW solution supplemented with L-NMMA was 11.10+/-2.03 IU/l, while that in UW solution alone was 3.70+/-0.70 IU/l (P<0.01). Together, our results suggest that NO protects SECs during cold preservation and that NO from SECs may have beneficial effects on the liver during cold ischemia.

The analysis of the usefulness of laparoscopic microwave coagulation therapy for hepatocellular carcinoma in patients with poor hepatic reserve by serial measurements of IL-6, cytokine antagonists, and C-reactive protein.

BACKGROUND: Little is known about the effectiveness of laparoscopic microwave coagulation therapy (L-MCT) for hepatocellular carcinoma (HCC) in patients with liver cirrhosis and poor hepatic reserve. Here, we analyzed the usefulness of laparoscopic MCT by comparing the serum levels of IL-6, cytokine antagonists, and C-reactive protein (CRP) following L-MCT with those following MCT with the open method (O-MCT). METHODS: Sixteen patients with hepatocellular carcinoma (HCC) were separated into L-MCT and O-MCT groups according to ICGR15 (ICGR15 30%<:L-MCT, 30%> :O-MCT). Nine patients with poorer hepatic reserve received L-MCT, while seven patients with relatively good hepatic reserve received O-MCT. Serum levels of cytokine antagonists (interleukin-6, IL-6; interleukin-1 receptor antagonist, IL-1ra; soluble tumor necrosis factor receptor type I, sTNF-R55) and C-reactive protein (CRP) were simultaneously measured on serial postoperative days (POD) by immunoassay. RESULTS: Postoperative serum levels of IL-6, IL-1ra, and CRP were significantly elevated on POD-1 and returned to the preoperative levels on POD-7 in both L-MCT and O-MCT groups. In contrast, no significant elevation of sTNF-R55 was found during the period in both groups. In addition, no statistical differences were found in the levels of IL-6, IL-1ra, sTNF-R, and CRP between the groups, except that the level of IL-6 on POD-1 in L-MCT group was significantly lower than that in the O-MCT group. CONCLUSION: These results suggested that the surgical stress by L-MCT in patients with poorer hepatic reserve were almost equal to that by O-MCT in patients with relatively good hepatic reserve, indicating the usefulness of L-MCT for HCC patients with poorer hepatic reserve. We recommend the laparoscopic approach for future patients with the criterion that ICGR15 is over 30%.

Calcineurin antagonists inhibit interferon-gamma production by downregulation of interleukin-18 in human mixed lymphocyte reactions.

Tacrolimus (FK-506) and cyclosporin A (CsA) are calcineurin antagonists used widely as T-cell immunosuppressants; however, their relative efficacy on the production of interleukin-18 (IL-18) remains undefined. We have examined the effects of FK-506 and CsA on the cytokine generation of human peripheral blood mononuclear cells (PBMCs) in mixed lymphocyte reaction (MLR) with lipopolysaccharide (LPS). We studied the levels of interleukin-18 (IL-18), IL-12, IL-10, IL-6, IL-2 and interferon-gamma (IFN-gamma) in the supernatant in allo-MLR by ELISA assay. Supernatant levels of IFN-gamma, IL-2, IL-6, IL-10 and IL-12 were detected 12 h after MLR and markedly increased thereafter. In contrast, production of IL-18 was detected at 12 h, reached a near maximum level at 24 h and decreased at 72 h. These results suggested that IFN-gamma production depended on IL-18, IL-12 and IL-2 in the early phase of MLR and depended mainly on IL-12 and IL-2 in the late phase. Both calcineurin antagonists inhibit the generation of IL-18, which plays a large role in allogeneic cell interactions, in macrophages and they also promote an equivalent down-regulation of T helper 1 (Th1) and Th2 responses in a concentration-dependent manner. About 90% of IFN-gamma production induced by MLR was inhibited by an anti-IL-18 antibody, showing that IL-18 can trigger IFN-gamma production in MLR. These results suggest that dual signaling consisting of antigen-driven nuclear factor of activated T cells (NFAT) activation and LPS-mediated NF-kappaB activation is crucial for IL-18 production in macrophages, and that IL-18 can trigger IFN-gamma production in T-cells by MLR.

Intraportal donor bone marrow transplantation improves intestinal allograft survival in rats under FK506-based immunosuppression.

Donor-specific immunosuppression is important in transplant surgery. We examined the effect of intraportal donor-specific bone marrow transplantation on heterotopic small bowel transplantation in the high responder rat combination, ACI to Lewis. The study comprised five treatment groups: untreated controls (group 1); FK506 alone (group 2); low-dose predonine + FK506 (group 3); high-dose predonine + FK506 (group 4); and intraportal donor-specific bone marrow transplantation + FK506 (group 5). Intraportal transplantation was performed pre-operatively and FK506 and predonine given post-operatively. Intestinal allograft survival and changes of intragraft cytokine expression were analysed using the reverse transcription polymerase chain reaction. Allograft survival (mean +/- SD) was lowest in group 1 and greatest in group 5. The group 5 treatment regimen also down-regulated interferon-gamma and interleukin-2 transcription in the transplanted intestine. Intraportal donor bone marrow transplant combined with FK506 immunosuppression was found therefore to be the most beneficial treatment regimen.

Activated T cells and soluble molecules in the portal venous blood of patients with cholestatic and hepatitis C virus-positive liver cirrhosis. Possible promotion of Fas/FasL-mediated apoptosis in the bile-duct cells and hepatocyte injury.

We investigated the immune responses of patients with cholestatic and hepatitis C virus-positive (HCV-positive) liver cirrhosis by analysing T-cell subsets and cytokine levels in the portal and peripheral veins, using flow cytometry and enzyme-linked immunosorbent assay. In cholestatic liver cirrhosis, the proportion of natural-killer (NK) T cells and interleukin (IL) 6 and IL-18 levels in the portal venous blood were significantly higher than those in the peripheral venous blood. In HCV-positive liver cirrhosis, the proportions of NK T cells and Fas+ T cells and IL-6 and soluble Fas levels in the portal venous blood were significantly higher than those in the peripheral venous blood. These results suggest that in these diseases, activated T cells and soluble molecules in portal venous blood may promote Fas/FasL-mediated apoptosis of the bile-duct cells and hepatocytes, and contribute to the deterioration in liver function as an inevitable result of positive feedback.

Analysis of host response to hepatectomy by simultaneous measurement of cytokines in the portal vein, caval vein and radial artery.

We analysed the host response to hepatectomy by simultaneous measurement of various cytokines and their antagonists in the portal vein, caval vein and radial artery in 10 patients with hepatocellular carcinoma. Concentrations of tumour necrosis factor-alpha (TNF), interleukin (IL) 1 beta, IL-2, IL-6, IL-10, soluble TNF receptor type I (sTNF-R), soluble IL-2 receptor (sIL-2R), IL-1 receptor antagonist (IL-1ra), soluble CD14 (sCD14) and endotoxin were determined just before and 1 h after hepatectomy. The values of IL-6, sTNF-R and IL-1ra were significantly increased after hepatectomy at each sampling site. In contrast, the levels of sIL-2R and sCD14 after hepatectomy were significantly decreased, and the levels of IL-1 beta, IL-2 and IL-10 were below the detection limits. Differences in cytokine concentrations between sampling sites revealed that the surgical stress of hepatectomy induced significant IL-1ra production in the liver and sTNF-R and IL-6 production in the lungs. These results suggest that hepatic resection is followed by the production of cytokine antagonists, such as IL-1ra, sTNF-R and IL-6, which could represent an important regulatory mechanism against surgical stress.

Donor dendritic cells and recipient Kupffer cells in the induction of donor-specific immune hyporesponsiveness.

The aim of this study was to investigate the ability of portovenously administered donor antigens to induce immune hyporesponsiveness. Lewis (LEW, RT-1l) rats received Brown Norway (BN, RT-1n) rat donor splenocytes, via either the portal vein (PV group) or the peripheral vein (IV group). The immune responses of LEW rats, treated with either donor BN or third party Wistar King A (WKA, RT-1k) splenocytes were established by the persistence of donor dendritic cells (DCs) in the host liver measured using fluorescence microscopy and flow cytometry and by the mixed lymphocyte reaction (MLR). The effect of intravenous gadolinium chloride (GDCl3) on the blockade of Kupffer cell function prior to portovenous administration of splenocytes was also assessed. The MLR response was strongly inhibited in a BN-restricted manner after portovenous administration of donor BN splenocytes, but not by venous nor by portovenous administration of WKA splenocytes. Immunosuppression was blocked by pretreatment with GDCl3. The percentage of donor DCs in hepatic non-parenchymal cells (NPCs) was significantly higher in the PV group compared with the IV group. Treatment with GDCl3 decreased the percentage of donor DCs. In addition, cytotoxic T lymphocyte antigen 4 (CTLA4/CD152), which may function as an immune attenuator, was strongly stained, and B7 was weakly stained in recipient liver in the PV group compared with the IV group. These results suggest that both donor DCs and recipient Kupffer cells (self DCs) are involved in the induction of immune hyporesponsiveness by donor cells. This occurs via portovenous administration, in which a signal of the CTLA4-B7 pathway played an important part in inhibiting the interaction of CD28 and its B7 ligands.

Increased heme oxygenase-1 gene expression in the livers of patients with portal hypertension due to severe hepatic cirrhosis.

Surgical bleeding associated with splanchnic hyperaemia due to portal hypertension complicates the anaesthetic management of hepatic transplantation. Although the mechanism(s) of portal hypertension are not fully understood, carbon monoxide, a product of the heme oxygenase (HO) reaction, is thought to be one of the endogenous vasodilators in the liver. In this study, the expression of mRNA encoding inducible HO isozyme (HO-1) in the livers of patients with portal hypertension undergoing hepatic transplantation was determined in comparison with those without portal hypertension. HO-1 mRNA levels were significantly greater in the portal hypertension group than in the group without portal hypertension. In contrast with HO-1, the gene expression of non-specific delta-amino-levulinate synthase (ALAS-N), which is down-regulated by heme in the liver, was the same in both groups. These results suggest that HO-1 is up-regulated through heme-independent stimuli according to the development of portal hypertension, and that induced HO-1 plays a pathophysiological role in portal hypertension through carbon monoxide production.

[A successful case of preoperative intermittent hepatic arterial infusion of high-dose 5-FU and pharmacokinetic modulating chemotherapy against unresectable liver metastasis of colon cancer].

A 46-year-old adult who underwent a sigmoidectomy for sigmoid colon cancer at the age of 44 was found to have a liver tumor 2 years after the first operation. His CEA was elevated to 158.8 ng/ml. An abdominal CT showed a huge mass of 10 x 7 x 7 cm in the anterior segment of right lobe of the liver invading into segment 4 and 7, which compressed the left hepatic vein and the umbilical portion of the portal vein. We diagnosed an unresectable liver metastasis of sigmoid colon cancer. Intermittent hepatic arterial infusion of high-dose 5-FU was started on a weekly schedule and oral UFT was added as pharmacokinetic modulating chemotherapy 4 weeks after the initial chemotherapy. Chemotherapy was continued for 13 weeks and the tumor shrunk up to 64%. An extended right hepatectomy was performed. Pathological examination showed residual cancer cells in the central part of the tumor, but fibrous degeneration and calcification were observed in the surrounding area and considered to be the effect of chemotherapy.

Histamine inhibits adhesion molecule expression in human monocytes, induced by advanced glycation end products, during the mixed lymphocyte reaction.

BACKGROUND AND PURPOSE: Post-transplant diabetes mellitus is a frequent complication among transplant recipients. Ligation of advanced glycation end products (AGEs) with their receptor on monocytes/macrophages plays important roles in the genesis of diabetic complications. The enhancement of adhesion molecule expression on monocytes/macrophages activates T-cells, reducing allograft survival. Out of four distinct AGE subtypes (AGE-2, AGE-3, AGE-4 and AGE-5), only AGE-2 and AGE-3 induced expression of intercellular adhesion molecules (ICAMs), output of cytokines and proliferation of lymphocytes, during the mixed lymphocyte reaction (MLR). Here we have assessed the role of histamine in the actions of AGEs during the MLR. EXPERIMENTAL APPROACH: Human peripheral blood cells were used in these experiments. Flow cytometry was used to examine the expression of the ICAM-1, B7.1, B7.2 and CD40. Production of the cytokine interferon-gamma, and levels of cAMP were determined by elisa. Lymphocyte proliferation was determined by [(3)H]-thymidine uptake. KEY RESULTS: Histamine concentration dependently inhibited the action of AGE-2 and AGE-3. The actions of histamine were antagonized by an H(2)-receptor antagonist, famotidine, and mimicked by H(2)/H(4)-receptor agonists, dimaprit and 4-methylhistamine. The effects of histamine were reversed by a protein kinase A (PKA) inhibitor, H89, and mimicked by dibutyryl cAMP and an adenylate cyclase activator, forskolin. CONCLUSIONS AND IMPLICATIONS: Histamine down-regulated AGE-2- and AGE-3-induced expression of adhesion molecules, cytokine production and lymphocyte proliferation via histamine H(2) receptors and the cAMP/PKA pathway.