Incidence of and risk factors for incisional hernia after abdominal surgery.

BACKGROUND: Few larger studies have estimated the incidence of incisional hernia (IH) after abdominal surgery. METHODS: Patients who had abdominal surgery between November 2009 and February 2011 were included in the study. The incidence rate and risk factors for IH were monitored for at least 180 days. RESULTS: A total of 4305 consecutive patients were registered. Of these, 378 were excluded because of failure to complete follow-up and 3927 patients were analysed. IH was diagnosed in 318 patients. The estimated incidence rates for IH were 5·2 per cent at 12 months and 10·3 per cent at 24 months. In multivariable analysis, wound classification III and IV (hazard ratio (HR) 2·26, 95 per cent confidence interval 1·52 to 3·35), body mass index of 25 kg/m(2) or higher (HR 1·76, 1·35 to 2·30), midline incision (HR 1·74, 1·28 to 2·38), incisional surgical-site infection (I-SSI) (HR 1·68, 1·24 to 2·28), preoperative chemotherapy (HR 1·61, 1·08 to 2·37), blood transfusion (HR 1·46, 1·04 to 2·05), increasing age by 10-year interval (HR 1·30, 1·16 to 1·45), female sex (HR 1·26, 1·01 to 1·59) and thickness of subcutaneous tissue for every 1-cm increase (HR 1·18, 1·03 to 1·35) were identified as independent risk factors. Compared with superficial I-SSI, deep I-SSI was more strongly associated with the development of IH. CONCLUSION: Although there are several risk factors for IH, reducing I-SSI is an important step in the prevention of IH. REGISTRATION NUMBER: UMIN000004723 (University Hospital Medical Information Network, http://www.umin.ac.jp/ctr/index.htm).

Clinical effect of hyperbaric oxygen therapy in adhesive postoperative small bowel obstruction.

BACKGROUND: Hyperbaric oxygen (HBO) therapy is a controversial treatment for adhesive postoperative small bowel obstruction, with only a few small studies reported. The aim of this study was to assess the clinical value of HBO therapy in the treatment of adhesive postoperative small bowel obstruction. METHODS: Between April 2006 and March 2012, all patients with adhesive postoperative small bowel obstruction were treated using either decompression therapy or HBO. Patients undergoing HBO therapy were treated once a day at a pressure of 2·0 atmospheres absolute and received 100 per cent oxygen. Patients showing no clinical and radiological improvement with HBO therapy were converted to decompression therapy by means of a long tube. Medical records were reviewed and outcomes analysed. RESULTS: A total of 305 patients were treated, of whom 142 underwent tube decompression therapy during the first 3 years and the remaining 163 had HBO therapy during the last 3 years. The median number of HBO treatments was 3 (range 1-7). A total of 143 patients (87·7 per cent) were treated successfully with HBO without long-tube decompression. HBO therapy was associated with earlier resumption of oral intake (mean 4·7 versus 6·5 days; P = 0·001) and a shorter hospital stay (mean 10·3 versus 14·1 days; P = 0·001). The rate of operation was 7·4 per cent in the HBO group and 14·8 per cent in group treated by decompression alone (P = 0·037). CONCLUSION: In this study, HBO therapy was safe for the treatment of adhesive postoperative small bowel obstruction. It reduced the need for surgery and time to recovery as well as the hospital stay.

Preoperative drainage using a transanal tube enables elective laparoscopic colectomy for obstructive distal colorectal cancer.

BACKGROUND AND STUDY AIMS: Acute colorectal obstruction (ACO) often accompanies colorectal cancer (CRC) and requires urgent treatment, but achieving elective laparoscopy-assisted colectomy (LAC) is difficult in this setting. The aim of the current study was to assess the clinical outcomes of a transanal tube (Dennis colorectal tube [DCT]) for CRC with ACO, focusing in particular on the impact of the DCT on subsequent elective LAC. PATIENTS AND METHODS: Among 1142 patients who underwent surgery for CRC between January 2007 and December 2011, 92 patients with ACO were identified retrospectively. Of these 92 patients, the DCT procedure was performed in 66 patients who fulfilled the indications for DCT, and these patients were included in the study. RESULTS: All 66 patients presented with complete obstruction. Technical and clinical success rates for DCT were 93.9 % and 86.4 %, respectively. Perforation after DCT occurred in 4.5 % and the mortality rate was 1.5 %. The rate of LAC was 48.5 %, and the rate of primary stoma was 13.6 %. For curative stage II/III CRC with ACO, DCT resulted in a primary stoma rate of 13.6 %, a one-stage surgery rate of 90.9 %, a LAC rate of 50.0 %, and a 3-year survival rate of 73.1 %. For stage II/III CRC cases with clinical success by DCT, the one-stage surgery rate was 97.4 % and the LAC rate was 56.4 %. CONCLUSIONS: DCT achieved a high rate of clinical success and enabled safe one-stage surgery and LAC for CRC with ACO. DCT followed by LAC is proposed as a promising non-invasive strategy for CRC with ACO.

Differential suppression of liver-specific genes in regenerating rat liver induced by extended hepatectomy.

BACKGROUND/AIMS: The function of the remnant liver is critical to survival of patients following an extended hepatectomy. The aim of this study was to determine whether proliferating hepatocytes in the remnant liver preserve the expression of liver-specific genes. METHODS: Using regenerating rat livers after 30, 70, and 90% partial hepatectomy (PHx), Northern blot analyses were performed with probes for seven liver-specific genes, six growth-related genes, two housekeeping genes and two acute phase reactant protein genes. RESULTS: During the regeneration after 90% PHx, the transcription of liver-specific genes showed three chronological patterns: transcription of serum albumin and cytochrome P450 2B decreased rapidly and reached a nadir at 6 to 24 h after PHx; those of apolipoprotein A-1, phosphoenolpyruvate carboxykinase and ornithine transcarbamylase decreased gradually until 24 to 48 h; those of UDP-glucuronosyltransferase and hepatocyte nuclear factor 4 did not show any changes until 48 h after PHx. In contrast, expression levels of all the growth-related genes and of housekeeping genes increased rapidly after PHx. After 30 and 70% PHx, expression of these genes changed in a similar manner to the 90% PHx case but to a lower extent. CONCLUSIONS: Based upon the fractions of Ki-67 positive hepatocytes in remnant livers, we could estimate the degree of expression of each liver-specific gene in the proliferating hepatocytes. The serum albumin gene was completely suppressed, while that encoding UDP-glucuronosyltransferase was not affected. These results correlated well with the patterns of albumin and bilirubin in rat serum after PHx. Other liver-specific genes were moderately suppressed in proliferating hepatocytes. Thus, expression of liver-specific gene is differentially suppressed when hepatocytes enter a proliferation cycle. Those that are unaffected may be indispensable for maintaining the homeostasis of the living organism.

Up-regulation of telomerase in primary cultured rat hepatocytes.

Telomerase is a unique reverse transcriptase involved in the maintenance of telomeric DNA, which is generally undetectable in normal human somatic cells. However, it has been found in organs of normal adult rodents including the liver. In order to elucidate relevant control mechanisms operating in normal somatic cells, we examined telomerase activity in primary cultured rat hepatocytes. During culture under serum-free conditions, rat hepatocytes rapidly lose the ability of organ-specific expression of serum albumin, apolipoprotein A-I, and hepatocyte nuclear factor 4, and the capacity for cytochrome P-450 induction by xenobiotics. The telomerase activity was found to be concomitantly increased about 2. 5-fold at 48 h and 3-fold at 72 h. Northern blot and RT-PCR analyses with primary cultured hepatocytes revealed the associated accumulation of rat telomerase RNA subunits (TR), and the mRNAs for a telomerase reverse transcriptase (TERT) and a telomerase-associated protein (TEP1). The activity of hepatocyte telomerase, which was elevated during the primary culture, increased further when the cells were stimulated with hepatocyte growth factor. In this case, however, the levels of TR, TERT, and TEP1 mRNA did not show any detectable changes.

Interleukin 6 in bile as an indicator of liver function after hepatectomy in patients with biliary tract carcinoma.

BACKGROUND: Interleukin (IL) 6 is one of the important components of the early signalling pathways leading to liver regeneration, and has been detected in the bile after liver transplantation. IL-6 concentrations in the bile were studied in an attempt to predict liver function after major hepatectomy for biliary tract carcinoma. METHODS: This study involved 24 patients without cirrhosis who underwent major hepatectomy for biliary tract carcinoma. The bile was sampled regularly through external biliary drainage tubes. IL-6 concentrations in bile and serum were measured using an enzyme-linked immunosorbent assay. RESULTS: Bile IL-6 concentrations increased 37-fold (from mean(s.e.) 56(13) pg/ml before hepatectomy to 2071(398) pg/ml on day 1 after operation) in patients without liver failure after hepatectomy (n = 18) and increased sevenfold (from 71(24) to 530(76) pg/ml) in patients with liver failure after hepatectomy (n = 6). The values were significantly lower in patients with liver failure than in those without liver failure (P < 0.05). The bile IL-6 concentration on day 1 after operation exhibited a significant negative correlation with the maximum serum total bilirubin concentration after hepatectomy. Although serum IL-6 concentrations were also increased in both groups after hepatectomy, there was no significant correlation with postoperative liver function. CONCLUSION: Increased bile IL-6 concentrations after hepatectomy may reflect liver regenerative capacity. Measurement of bile IL-6 concentrations may be clinically useful for the early identification of liver failure after hepatectomy.

Active form of human hepatocyte growth factor is excreted into bile after hepatobiliary resection.

BACKGROUND/AIMS: We have shown that hepatocyte growth factor is excreted into bile after hepatectomy in patients with biliary tract carcinoma. However, it is not certain whether hepatocyte growth factor in bile is an active molecule or degradation products. METHODS: Bile was obtained from five patients after hepatobiliary resection. Bile hepatocyte growth factor was purified on a heparin-Sepharose column and subjected to Western blotting. It was also tested for growth-stimulating activity with rat primary cultured hepatocytes. Biles from 50 patients who underwent various types of hepatobiliary resections were examined with respect to hepatocyte growth factor by an enzyme-linked immunosorbent assay. RESULTS: Upon Western blotting following nonreducing electrophoresis, the purified bile hepatocyte growth factor showed an 85 kDa peptide corresponding to native hepatocyte growth factor. Under reducing conditions, it showed bands of a-subunit at 69 kDa and beta-subunit at 34 kDa with corresponding monoclonal antibodies. The purified bile hepatocyte growth factor stimulated the [3H]thymidine incorporation into primary cultured hepatocytes with a specific activity comparable to recombinant human hepatocyte growth factor. It was observed that the levels of bile hepatocyte growth factor increased after the various types of hepatobiliary resections, including bile duct resection without hepatectomy. CONCLUSIONS: The human bile obtained after hepatobiliary resection contains active hepatocyte growth factor that can stimulate hepatocyte growth. Bile hepatocyte growth factor increased not only in hepatectomy but in bile duct resection. These results suggest that the biliary tract system may play an important role in the production of bile hepatocyte growth factor.

Human hepatocyte growth factor in bile: an indicator of posthepatectomy liver function in patients with biliary tract carcinoma.

We measured the concentration of hepatocyte growth factor (HGF) in bile obtained from patients after hepatectomy. The HGF concentrations in the bile samples were quantified using an enzyme-linked immunosorbent assay (ELISA). By immunoblotting, using a monoclonal antibody raised against the HGF alpha-subunit, the bile HGF, which was purified on a Heparin-Sepharose column, showed a band of the same size as the recombinant HGF alpha-subunit (69 kd). Bile samples were obtained from 24 patients with biliary tract disease before and after hepatectomy by means of biliary drainage. Before surgery, the bile HGF concentrations were minimal (0.8 +/- 0.1 ng/mL); however, after hepatectomy on postoperative day 1 in patients without posthepatectomy liver failure (20 of 24), they increased severalfold (4.1 +/- 0.4 ng/mL, P < .05). The patients with posthepatectomy liver failure (4 of 24) showed no significant increase in bile HGF after hepatectomy (less than 2 ng/mL on postoperative day 1). The volume of the remnant liver correlated positively with the bile HGF concentration. The bile HGF concentration on postoperative day 1 exhibited a significant negative correlation with the maximum concentration of serum total bilirubin after hepatectomy. The concentration of bile HGF was generally higher than that in serum (2.1-fold). Thus, the bile HGF concentration after hepatectomy may be useful for the early assessment of posthepatectomy liver function.

[Two cases of multiple liver metastases (H3) from colon cancer treated by home hepatic arterial infusion chemotherapy].

Two cases with unresectable multiple liver metastases to both lobes (H3) from colon cancer, in which cases the life expectancy usually does not exceed 1 year, were treated with home hepatic arterial infusion chemotherapy employing implantable port system. They could live over one year with good performance status. Drug treatment consisted of the administration of carboplatin (CBDCA), 150 mg/body, given in a minute for one day and 5-fluorouracil (5-FU), 250 mg/body, given in a 5-hour intra-arterial infusion daily for 5 days. Cycles were administered every 2 weeks. Home hepatic arterial infusion chemotherapy using an implantable port system, which offers good local control of liver metastases, a high patient quality of life without the need for hospitalization, is suitable for treatment of unresectable liver metastases.