[Assessment of Long-Term Sexual Function after Radical Resection for Lower Rectal Cancer].

The aim of this study was to evaluate the long-term sexual function and risk factors of dysfunction after the autonomic nerve preserving operation for lower rectal cancer. METHODS: We evaluated postoperative sexual function assessed by IIEF5 in 91 patients who responded to the questionnaire by mail. RESULTS: After a median follow-up of 5.5 years, univariate analysis identified 4 risk factors associated with poor sexual function: the elder, over 3 years after surgery, pathological stage III , and lateral lymph node dissection(both side). Poor sexual function assessed by multivariate analysis was significantly associated with the elder(over 60 years). CONCLUSION: From the viewpoint of sexual dysfunction, the autonomic nerve preserving operation( AN4)should be considered for elderly people.

[Assessment of Functional Results after Sphincter-Preserving Surgery in Elderly Patients with Low Rectal Cancer].

The aim of this study was to evaluate postoperative dysfunction and potential problems after a sphincter-preserving operation in elderly patients with low rectal cancer. METHODS: Between 2000 and 2012, 307 consecutive patients with low rectal cancer underwent curative sphincter-preserving surgery. We evaluated postoperative anal and urinary dysfunction in 190 patients who responded to a questionnaire by mail. RESULTS: After a median follow-up of 5.7 years, there was no significant difference between the elderly and a younger group in the Wexner incontinence score. Poor anal function assessed by modified FIQL was significantly associated with the elderly. Poor urinary function assessed by the IPSS score was significantly associated with the elderly, diabetes mellitus, and autonomic nerve preservation(AN2-3). CONCLUSION: From the viewpoint of urinary function, sphincter-preserving surgery with all autonomicnerve preservation(AN4)should be considered for elderly people and patients with diabetes.

[Regrowth of Isolated Local Residual Tumor Effectively Treated with Chemoradiotherapy More Than Five Years after a Resection for Pancreatic Cancer with an Involvement of the Portal Vein].

A 55-year-old man who presented with abdominal pain was diagnosed with pancreatic head cancer involving the portal vein. He underwent pylorus-preserving pancreaticoduodenectomy without a resection of the portalvein, resulting in a macroscopic residualtumor, because radicalresection was impossible owing to the severe localinvasion. Postoperative chemotherapy( GEM plus S-1)was administered. The tumor size decreased and CA19-9 values normalized. Five years after the resection, chemotherapy was stopped. The regrowth of an isolated local residual tumor without a distant metastasis was diagnosed 65 months after the resection. He underwent chemoradiotherapy(CRT)with S-1. The size of the tumor remained stable, but FDG-PET demonstrated a disappearance of high FDG uptake in the tumor and CA19-9 values normalized. We reported a case in which CRT was an effective treatment for the regrowth of localresidualtumor after resection for pancreatic cancer.

A bioartificial liver that combines plasma dialysis and whole liver perfusion.

BACKGROUND/AIMS: The development of a bioartificial liver with xenogeneic hepatocytes requires sufficient hepatocyte mass for metabolic support, decreased immunogenicity, and prevention of viral transmission. Therefore, the authors developed a plasma dialysis system using a selective plasma filter, and combined this dialysis system with whole liver plasma perfusion (PDWLP). In this system, the patient's plasma was dialyzed with normal plasma recycled through the pig liver. METHODOLOGY: Female inbred Large White pigs were used for the hepatic failure model and for liver donation. Fulminant hepatic failure (FHF) was induced by the intraportal administration of alpha-amanitin and lipopolysaccharide. Nine hours after this injection, the FHF pigs were connected to the dialysis system for 6 h (n = 5). Control FHF pigs were not connected to the dialysis system (n = 10). RESULTS: Animal survival was lengthened, and cardiovascular stability was demonstrated in the PDWLP treated pigs. This system suppressed the production of substances that promote encephalopathy. The liver necrosis and neutrophil infiltration were significantly less in the experimental pigs. CONCLUSIONS: The experimental treatment attenuated the progression of FHF. Extracorporeal liver, perfused with oxygenated plasma, functioned for 6 h without hyperacute rejection. This type of hybrid bioartificial liver may be useful for treating FHF patients.

Heterotopic gastrointestinal mucosa and pancreatic tissue in a retroperitoneal tumor.

We believe that this is the first report of a retroperitoneal tumor consisting of heterotopic gastrointestinal mucosa and pancreatic tissue. The patient was a 19-year-old woman with the chief complaint being occasional back pain. Abdominal computerized tomography demonstrated a 3.1 x 2.5 x 3.2-cm low-density solid and cystic lesion adjoining the left renal vein between the aorta and inferior vena cava. Angiography revealed that the inferior vena cava was displaced by the hypovascular tumor. The retroperitoneal lesion was diagnosed preoperatively as a benign tumor such as a neurogenic neoplasm or lymphangioma. At laparotomy, a cystic tumor was found, which existed behind the inferior vena cava and renal vessels, and contained reddish-brown fluid, suggesting hemorrhage in the past. The cut surface of the tumor showed a unilocular cyst with partially hypertrophic wall. Histopathological examination revealed a cystic tumor lined with heterotopic gastric and duodenal mucosa, with pancreatic tissue in the muscularis propria. In addition, evidence of bleeding from the gastric mucosa was observed in the cystic tumor. External secretion from these tissues could have triggered the hemorrhage and expanded the tumor, possibly resulting in the back pain.

Attenuation of graft injury in porcine liver transplantation from non-heart beating donor by FR167653.

BACKGROUND/AIMS: Orthotopic liver transplantation (OLTx) from non-heart beating donor (NHBD) often involves hepatic warm ischemia and reperfusion injury which is triggered by the inflammatory cytokines. This study was carried out to investigate whether a newly synthesized cytokine suppressive anti-inflammatory agent, FR167653, attenuates graft injury in OLTx from NHBD. METHODOLOGY: Porcine OLTx from NHBD was performed. No-heart beating time was scheduled to be 60 minutes. Animals were divided into two groups: no treatment control (CT) group (n=5), and FR167653 treated (FR) group (n=5), in which FR167653 was administered intravenously before the aortic cross clamp in the donor, and before and after the hepatic allograft reperfusion in the recipient continuously. RESULTS: Four out of five pigs died within 24 hours and one on postoperative day 1 from graft liver failure in the CT group, while two pigs died on day 3, and three survived more than 7 days in the FR group (p<0.05). Microcirculatory disturbance was attenuated, liver injury was lessened, and ATP resynthesis was enhanced in the FR group. Additionally, FR167653 inhibited neutrophils infiltration in the liver tissue, and suppressed release of inflammatory cytokines after OLTx from NHBD. CONCLUSIONS: The treatments with FR167653 successfully prevented graft injury after OLTx from NHBD by means of improvement of liver microcirculation, and attenuation of neutrophils activation. The inhibitory effect of FR167653 on the release of inflammatory cytokines played an important role in the liver graft protection.

Porcine partial liver transplantation: a novel model of the "small-for-size" liver graft.

Increasing shortage of cadaveric grafts demands the utilization of living donor and split liver grafts. The purpose of this study was to 1) define the "small-for-size" graft in a pig liver transplant model 2) evaluate pathological changes associated with small-for-size liver transplantation. Pigs were divided into four groups based on the volume of transplanted liver: (a) control group (n=4), 100% liver volume (LV) (b) group I (n=8), 60% LV (c) group II (n=8), 30% LV (d) group III (n=15), 20% LV. Tacrolimus and methyl prednisone were administered as immunosuppression. Animals were followed for 5 days with daily serum biochemistry, liver biopsies on day 3 and 5 for light microscopy, and tissue levels of thymidine kinase (TK) and ornithine decarboxylase (ODC). Liver grafts were weighed pretransplant and at sacrifice. All the recipients of 100%, 60%, and 30% grafts survived. Transplantation of 20% grafts (group III) resulted in a 47% mortality rate. Group III animals showed significantly prolonged prothrombin times (p<0.05), elevated bilirubin levels (p<0.05), and ascites. The rate of regeneration, as indicated by TK activity and graft weight was inversely proportional to the size of the transplanted graft. The severity of the microvascular injury was inversely proportional to graft size and appeared to be the survival-limiting injury. Frank rupture of the sinusoidal lining, parenchymal hemorrhage, and portal vein injury were prominent in group III animals 1 hour following reperfusion. This study established a reproducible large animal model of partial liver grafting; it defined the small-for-size syndrome in this model and described the associated microvascular injury.

Current status of autonomic nerve-preserving surgery for mid and lower rectal cancers: Japanese experience with lateral node dissection.

Surgical practices for treatment of rectal cancer in Japan have changed from extended dissection along perivascular or parietal plane to pelvic autonomic nerve-preserving procedures without compromising radicality of surgical resection. Previous surgical results suggested the significant advantages of extended surgery in survival and local recurrence rate of Dukes B and C patients. More than 15 percent of patients with cancer in the lower rectum have extramesorectal spread to lateral pelvic nodes that can be removed by lateral dissection for local control and cure. Initially the total nerve-preserving procedure has been introduced for a complete preservation of para-aortic and intrapelvic nervous system in patients with early-stage cancer not requiring para-aortic and lateral lymph-node dissection. However, the concept of aggressive surgery for advanced rectal cancer has led to various types of pelvic autonomic nerve-preserving procedures, in which extended lymph-node dissection plus nerve-preserving technique with resection of one or more autonomic nervous segments has been performed. During two decades, total pelvic autonomic nerve-preserving procedure with lateral lymph-node dissection has been used increasingly for Dukes C lesion without increased local recurrence. The overall status of pelvic autonomic nerve-preserving procedures according to clinical experiences in Japan is reviewed in the context of cadaveric anatomic findings, Japanese vs. Western techniques and concepts, and our own clinical data.

Attenuation of microcirculatory disturbance after liver ischemia by newly synthesized inflammatory cytokine suppressor, FR167653.

BACKGROUND/AIMS: Inflammatory cytokines, such as interleukin-1 beta and tumor necrosis factor-alpha, which activate neutrophils, contribute to hepatic warm ischemia-reperfusion injury. However, the role of the cytokines in hepatic microcirculation immediately after reperfusion is still unclear. This study was carried out to investigate whether FR167653, a dual inhibitor of interleukin-1 beta and tumor necrosis factor-alpha, attenuates hepatic microcirculatory disturbance at the initial phase of reperfusion following liver ischemia. METHODOLOGY: Adult mongrel dogs were subjected to 90 minutes of liver ischemia by a Pringle's maneuver under portosystemic bypass. The animals were divided into two groups: a control group (n = 10), subjected to hepatic warm ischemia only, and a FR167653 administered group (n = 5), which received 1 mg/kg/h FR167653 for 4 hours since 30 minutes before the ischemia to 2 hours after the reperfusion continuously. Seven days animal survival, hepatic tissue blood flow, liver function test, hepatic venous blood concentration of endothelin-1 and plasminogen activator inhibitor-1, liver tissue biochemistry, and histopathology were analyzed. RESULTS: The treatment with FR167653 attenuated microcirculatory disturbance, lessened liver injury, enhanced adenine nucleotides resynthesis, and improved animal survival after liver ischemia. In addition, FR167653 significantly inhibited release of both endothelin-1 and plasminogen activator inhibitor-1 from the liver cells. CONCLUSIONS: These results suggest that the inflammatory cytokines induce microcirculatory disturbance in the initial phase of reperfusion following liver ischemia.

Influence of cold ischemia time and graft transport distance on postoperative outcome in human liver transplantation.

PURPOSE: The association between hepatic allograft cold ischemia time (CIT) and graft transport distance (GTD) in human liver transplantation was examined by investigating whether extended graft transportation prolongs the CIT and adversely affects graft survival. METHODS: We retrospectively analyzed 186 consecutive orthotopic liver transplants (OLTs) done between May 1997 and July 1998. The number of miles from the donor hospital to the University of Pittsburgh Medical Center in a straight line was measured in each case, and defined as the GTD. The OLTs were divided into two groups according to whether the GTD was 200 miles. The latter group was then subdivided into groups of GTD 200-400 miles, GTD 400-600 miles, and GTD >600 miles. The CIT and graft outcome within 90 days after OLT were assessed. RESULTS: Extended GTD prolonged the CIT ( P < 0.001). The rate of hepatic allograft loss in the long GTD group was significantly higher than that in the short GTD group ( P = 0.018). When the OLTs were subdivided according to GTD, the CIT increased and graft survival decreased as the GTD extended. Hepatic allograft transportation for a long distance prolonged the CIT and decreased the graft survival rate. CONCLUSION: Since prolonged CIT is a major risk factor, avoiding long-distance graft transportation is recommended when the donor risk factors are high.