Hepatogastroenterology

Subsegmentectomy or segmentectomy in hepatocellular carcinoma.

Year 1998
Miyagawa S. Kawasaki S.
First Department of Surgery, Shinshu University, School of Medicine, Matsumoto, Japan.
BACKGROUND/AIMS: We determined the optimal therapeutic strategy for improving survival in patients with hepatocellular carcinoma (HCC), based on an analysis of our surgical results. METHODOLOGY: Between January 1990 and December 1996, 205 patients underwent initial curative hepatectomy. The liver volume to be resected was decided according to the plasma retention of indocyanine green 15 minutes after injection. The appropriate subsegmental and segmental areas were disclosed by staining under ultrasonographic guidance. Limited resection or tumor enucleation was performed in 119 patients, subsegmentectomy or segmentectomy in 71, and lobectomy or extended lobectomy in 15. RESULTS: Intrahepatic recurrence was documented in 115 patients, 46 of whom died from cancer recurrence. Disease free survival was 65% after 1 year, 35.1% after 3 years and 25.3% after 5 years. The type of hepatectomy (limited vs. subsegmental or segmental resection) significantly affected the cumulative survival (p = 0.047) and disease free survival rates (p < 0.01). Among the 115 patients with recurrence, 22 patients underwent repeated hepatectomy combined with TAE (transcatheter arterial embolization) and the remainder underwent TAE alone. Patients who underwent repeated hepatectomy combined with TAE survived significantly longer after recurrence than those who underwent TAE alone (p = 0.0197). CONCLUSION: Initial subsegmentectomy or segmentectomy prolongs disease free survival, and patients eligible for repeated hepatectomy combined with TAE after recurrence have a good chance of long-term survival. Subsegementectomy or segmentectomy should be performed in a lot more HCC patients in order to improve survival.

Segmental liver resections for hilar cholangiocarcinoma.

Year 1998
Nagino M. Nimura Y. Kamiya J. Kanai M. Uesaka K. Hayakawa N. Yamamoto H. Kondo S. Nishio H.
First Department of Surgery, Nagoya University School of Medicine, Japan.
BACKGROUNDS/AIMS: Liver resection for hilar cholangiocarcinoma is now popular, and combined en bloc resection of the caudate lobe has become general practice, especially in Japan and some European countries. However, surgical procedure is not yet standardized, and many problems concerning surgical treatment of this disease still remain unsolved. METHODOLOGY: From April 1977 to December 1996, 173 patients with hilar cholangiocarcinoma were treated at The First Department of Surgery, Nagoya University Hospital. Of the 173 patients, 138 patients underwent surgical resection, including 124 liver resections and 14 bile duct resections. RESULTS: Several kinds of hepatic segmentectomy with en bloc resection of the caudate lobe were performed in the 124 patients: 109 underwent hepatic lobectomy or more extensive resection including central bisegmentectomy; 15 received resection of one or less segment of the liver. Aggressive resections, including combined portal vein and liver resection (n = 41) and hepatopan-creatoduodenectomy (n = 16), were applied to advanced hilar cholangiocarcinoma. The hospital death rate in hepatectomized patients was 9.7% (12/124). The 3- and 5-year rates for the 97 patients with curative hepatectomy were 42.7%, and 25.8%, respectively. CONCLUSIONS: Aggressive liver resection improves survival of patients with hilar cholangiocarcinoma. Resection procedures should be designed based on a precise diagnosis of the extent of carcinoma.

Bisubsegmental liver resection for gallbladder cancer.

Year 1998
Yoshikawa T. Araida T. Azuma T. Takasaki K.
Division of Surgery, Institute of Gastroenterology, Tokyo Women's Medical College.
BACKGROUNDS/AIMS: The ultimate goal was to determine the therapeutic value and indications of resection of segment IV inferior and segment V in patients with advanced gallbladder cancer. METHODOLOGY: Indications for systematic resection of the liver, particularly segment IV inferior and segment V as defined by Couinaud (1) or Healey (2), in patients with advanced gallbladder cancer, were examined in a total of 201 patients with advanced gallbladder cancer who underwent surgical resection were studied. RESULTS: All primary tumors invaded the subserosa of the gallbladder wall or deeper. Liver invasion and liver metastasis were studied clinicopathologically, and the long-term outcome was analyzed according to the procedure used for liver resection. CONCLUSION: The clinicopathological result suggests that resection of segment IV inferior and segment V of the liver may be beneficial in patients with liver bed type invasion less than 20 mm in depth.

Segmental liver resections, present and future-caudate lobe resection for liver tumors.

Year 1998
Takayama T. Makuuchi M.
Second Department of Surgery, Faculty of Medicine, University of Tokyo, Japan. takayamat-2su@h.u-tokyo.ac.jp
BACKGROUND/AIMS: Resection of the caudate lobe of the liver is difficult to perform because of a deep location and an adjacency to the major vessels. METHODOLOGY: A total of 30 patients with hepatocellular carcinoma (HCC) originating in the caudate lobe underwent hepatic resection. The lobe was classified to Spiegel's portion, the process portion, and the caval portion. The operative procedure undertaken was chosen on the basis of tumor location as well as hepatic function of each patient. RESULTS: In 14 patients who had an HCC located at Spiegel's portion or the process portion, the tumor was removed by local resection of the caudate lobe (n = 10), or by resection combined with lobectomy (n = 2) or subsegmentectomy (n = 2). In 16 patients with an HCC at the caval portion, caudate lobe resections with preparatory lobectomy (n = 6), segmentectomy (n = 1), or subsegmentectomy (n = 4) were performed. In the other 5, isolated total or partial resection of the caudate lobe was carried out because of the presence of severe cirrhosis. All operations were defined as curative, but produced two operative deaths due to liver failure. The cumulative rate of overall survival was 41% at 5 years after surgery. CONCLUSIONS: Caudate lobe resection for HCC can be performed even in cirrhotic patients with a favorable surgical outcome.

Resection of metastatic liver tumors with special reference to hepatic venous system.

Year 1998
Nakamura S. Suzuki S. Konno H. Baba S.
Second Department of Surgery, Hamamatsu University School of Medicine, Japan.
BACKGROUND/AIMS: When the right and middle hepatic veins (RHV and MHV) and all the short hepatic veins are removed during resection of segments (S) 7 + 8 including the caudate lobe, the remainder of (S) 5 + 6 shows congestion. METHODOLOGY: The subjects were 8 patients undergoing hepatectomy (7 with hepatic metastases of colorectal carcinoma and 1 with pancreatic carcinoid) for tumors located in the region circumscribed by the RHV, MHV, and inferior vena cava. Direct hepatic vein anastomosis was done in 5 patients, graft replacement of the MHV was done in 1 patient, and graft replacement of the RHV was done in 2 patients. RESULTS: Hepatic vein reconstruction took approximately 20 min to complete. All 8 patients had an uneventful postoperative course and the anastomosis was patent at one month after operation. Three patients died of recurrent carcinoma at 6, 30, and 48 months after operation, respectively. Five have remained alive and disease-free for 18, 30, 46, 67, and 79 months, respectively. CONCLUSION: Hepatic vein reconstruction is a beneficial option in hepatectomy for patients with carcinoma invading the major hepatic veins and short hepatic veins, since it can allow radical tumor resection and preserves the remnant liver function. In particular, direct hepatic vein anastomosis is recommended because it is a simple technique with good results.

Laparoscopic partial hepatectomy.

Year 1998
Yamanaka N. Tanaka T. Tanaka W. Yamanaka J. Yasui C. Ando T. Takada M. Maeda S. Okamoto E.
First Department of Surgery, Hyogo College of Medicine, Nishinomiya, Japan.
This article describes the surgical techniques and indications of laparoscopic partial hepatectomy, which is not as widely available as laparoscopic cholecystectomy. Three patients with hepatocellular carcinoma and associated severe liver cirrhosis were candidates for this technique from July 1993 to August 1994. The tumor size was 4 cm or less and all the tumors were located in segment 5 or 8 which had grown nodularly and protruded from the liver surface. A microwave tissue coagulator was used for parenchymal dissection under ultrasonographic guidance in a gas-less method with or without low-pressure pneumoperitoteum of 4 mmHg. The principle of dissection consists of tissue coagulation and fragmentation with dissecting forceps. Three hepatectomies were performed uneventfully without blood transfusion and the patients rapidly returned to their preoperative conditions. The laparoscopic partial hepatectomy can be an option of treatment in selected cases where the tumor can be removed by minor, superficial resection.

Mesenteric vein thrombosis: a rare cause of abdominal pain in cirrhotic patients--two case reports.

Year 1998
Venturini I. Cioni G. Turrini F. Gandolfo M. Modonesi G. Cosenza R. Miglioli L. Cristani A. D'Alimonte P. De Santis M. Zeneroli ML.
Dipartimento di Medicina Interna, Universita di Modena, Italy.
Mesenteric vein thrombosis is a rare disorder which can develop rapidly with intestinal infarction or subacutely with abdominal pain due to intestinal ischemia. Despite the availability of modern diagnostic tools, which allow an early diagnosis in most cases, the mortality from this disease has not significantly diminished over the years. The problem is that the syndrome is rare and unusual and the clinical presentation is usually vague or confusing. Particularly in cirrhotic patients, this diagnosis requires the exclusion of several other complications of liver disease, like spontaneous bacterial peritonitis, tense ascites or portal thrombosis. Here, we report the occurrence of acute mesenteric vein thrombosis in two patients with liver cirrhosis. Severe subcontinuous abdominal pain out of proportion to the physical findings and abdominal distension were the major symptoms in both patients. Magnetic resonance imaging in one case and ultrasound scan with color Doppler followed by computed tomography in the other patient confirmed the diagnosis and enabled an appropriate early therapy to be undertaken.

Transcutaneous ultrasound of gastric pathology.

Year 1998
al Karawi MA. Abdel Bagi ME. Mohamed AE.
Department of Gastroenterology and Radiology, Riyadh Armed Forces Hospital, Saudi Arabia.
BACKGROUND/AIMS: Examination of the stomach during transcutaneous upper gastrointestinal ultrasound is often ignored. Two thousand seven hundred and eighty patients were referred for endoscopy over the period of August 1994 until August 1995. Nearly half of those patients underwent transcutaneous ultrasound. We report on the ultrasonographic demonstration of gastric pathology in 18 patients. METHODOLOGY: The stomach was examined in a collapsed state after an overnight fast. No paralytic agents or water distention were used. RESULTS: Seven patients had gastric tumors. Six patients had diffuse gastric wall thickening. Large varices were seen in two patients. A patient with multiple ulcers showed irregular walls. Two patients had retained gastric contents. CONCLUSIONS: Results of the ultrasound matched well with endoscopic findings. We recommend that in all abdominal ultrasounds, the stomach should be examined carefully and evaluated systematically.

Esophagocoloplasty in the management of postcorrosive strictures of the esophagus.

Year 1998
Yararbai O. Osmanodlu H. Kaplan H. Tokat Y. Coker A. Korkut M. Kapkac M.
Ege University Medical School Hospital, Department of General Surgery, Izmir, Turkey.
BACKGROUND/AIMS: Esophageal replacement therapy has developed an increasing role in the management of severe esophageal strictures due to caustic ingestion. The aim of this study is to discuss methods of reconstruction and results of them in corrosive esophagitis at our Institute. METHODOLOGY: Thirty-three patients underwent 34 esophagocoloplasties for benign strictures of the esophagus over a 17-year period. The left colon was used in 8 patients, the right colon in 3 patients, and the right colon with the terminal ileum in 23 patients. RESULTS: Three patients died in the first postoperative month, and there was an overall mortality rate of 9%. The most severe complication was graft necrosis (2 patients). The remainder of the patients survived without any deleterious complications. CONCLUSION: Esophageal replacement therapy using the right colon with the terminal ileum is superior to the modalities in terms of the continuity of peristalsis of the interposed bowel segment with an intact ileocecal valve, which decreases the hazard of regurgitation from the colon. It is also easier to perform an anastomosis between the ileum and the cervical esophagus from the point of view of surgical manipulation.

Management of postoperative biliary strictures secondary to hepatic hydatid disease by endoscopic stenting.

Year 1998
Yilmaz U. Sakin B. Boyacioglu S. Saritas U. Cumhar T. Akoglu M.
Department of Gastroenterology, Surgery and Radiology, Yuksek Ihtisas Hospital, Ankara, Turkey.
BACKGROUND/AIMS: The cases in the present study were reviewed retrospectively with the aim to demonstrate the characteristics of these strictures as well as the effectiveness of endoscopic stenting and to discuss the possible mechanisms of stricture formation. METHODOLOGY: Thirteen cases of postoperative benign biliary strictures secondary to hepatic hydatid disease (HHD) surgery were diagnosed between 1989 and 1994. All of these cases had had surgery for HHD one or more times. Endoscopic stenting was performed in 11 of the cases. Eight cases were followed-up. RESULTS: In 3 (29%) of the 8 cases, the stents were removed after a mean period of 35.6 months, and the patients were considered cured. These cases have been followed-up for 28 months. The remaining 5 cases have been followed-up for a mean period of 14.2 months. The overall morbidity was 18%, and there were no mortalities. The postoperative benign biliary strictures secondary to HHD were long, multiple, and located proximally. Due to these properties, surgical repair was not indicated for these cases. CONCLUSION: Endoscopic stenting is a safe method in the treatment of postoperative benign biliary strictures secondary to hepatic hydatid disease.

Intensified ESWL of gallstones: dissociation of pulverisation, pain relief and stone-clearance.

Year 1998
Brand B. Groth J. Lerche L. Stange EF.
Department of Internal Medicine I, University of Lubeck, Germany.
BACKGROUND/AIMS: Recently, intensified shock wave lithotripsy for gallstone pulverisation and subsequent clearance without bile salt medication has been advocated. We report our first 44 patients treated by this regime: Patients with intact gallbladder function and symptomatic gallstones of any size, number and composition. METHODOLOGY: Forty-four consecutive patients who received intensified shock wave lithotripsy for gallstone pulverisation and clearance were included in this study. The patients all had intact gallbladder function and presented with symptomatic gallstones of any size, number and composition. RESULTS: Pulverisation was achieved in 75% of all cases (12 months), but only 34% were stone free. The proportion of patients with stone pulverisation compared to subsequent complete clearance was 93% versus 60% in small (

Increased serum CA19-9 in patients with xanthogranulomatous cholecystitis.

Year 1998
Adachi Y. Iso Y. Moriyama M. Kasai T. Hashimoto H.
Department of Surgery, Saiseikai Yahata General Hospital, Kitakyushu, Japan.
We present three cases of xanthogranulomatous cholecystitis (XGC) with an increased serum carbohydrate antigen 19-9 (CA19-9). All of the patients were elderly females and had gallstones lodged in the neck of the gallbladder. Preoperative serum CA19-9 levels were 709 U/ml, 87 U/ml, and 400 U/ml, respectively. A cholecystectomy with or without bile duct exploration was performed, and the histological diagnosis of XGC was made. Serum CA19-9 levels fell to normal levels in two patients who recovered uneventfully, but rose again in one patient who died of cholangitis. Clinicians must remember that XGC is a possible cause of increased serum CA19-9 levels.

Laparoscopic cholecystectomy may disseminate gallbladder carcinoma.

Year 1998
Shirai Y. Ohtani T. Hatakeyama K.
Department of Surgery, Niigata University School of Medicine, Japan.
Laparoscopic cancer surgery has been reported to facilitate tumor dissemination. In our experience with 158 laparoscopic cholecystectomies, we encountered 2 cases (1.3%) of unsuspected gallbladder cancer. We report these 2 cases to illustrate the disadvantages of laparoscopic tumor resection. In Case 1, a 60-year-old woman with symptomatic cholecystolithiasis underwent a laparoscopic cholecystectomy revealing an unsuspected gallbladder cancer (pT2). Five months later, localized peritoneal carcinomatosis developed in the right subphrenic space, and she died from disseminated disease 19 months postoperatively. Laparoscopic manipulation may have caused the unusual, localized seeding. In Case 2, laparoscopic cholecystectomy was initiated for a polypoid lesion of the gallbladder in a 69-year-old man. When laparoscopy revealed a concomitant cancer (pT3), resection was converted to an open radical cholecystectomy. He remains alive without evidence of disease 31 months postoperatively. Conversion to open surgery may have contributed to the favorable outcome. The contrast between the 2 cases suggests that laparoscopic cholecystectomy should be converted to open surgery whenever malignancy is suspected. Surgeons should note that laparoscopic resection may disseminate cancer.

A case report of biliary cystadenoma and cystadenocarcinoma.

Year 1998
Siren J. Karkkainen P. Luukkonen P. Kiviluoto T. Kivilaakso E.
Helsinki University Central Hospital, Department of Surgery.
Three cases of intrahepatic biliary cystadenoma with mesenchymal stroma and one case of biliary cystadenocarcinoma are presented. Their immunohistochemical features and the surgical treatment are discussed together with a brief review of the literature. The benign cystadenomas stained positive for cytokeratin and CA 19-9 in the epithelium of the cyst wall. Mesenchymal stromal cells were strongly positive for a-SMA and moderately positive for desmin. The epithelium of the cystadenocarcinoma, however, was positive only for cytokeratin and the stroma only for a-SMA. Our findings indicate that biliary cystadenomas seem to be of primitive hepatobiliary origin. Furthermore, the malignant variant cystadenocarcinoma may loose its immunoreactivity for CA 19-9 and desmin.

Achalasia: a prospective study comparing the results of dilatation and myotomy.

Year 1998
Felix VN. Cecconello I. Zilberstein B. Moraes-Filho JP. Pinotti HW. Carvalho E.
Department Professors, Hospital das Clinicas, Faculdade de Medicina, Universidade de Sao Paulo (FMUSP).
BACKGROUND/AIMS: In a prospective and randomized clinical study, the operative method and dilatation in the initial stage of megaesophagus were evaluated. METHODOLOGY: Forty patients in the initial stage of megaesophagus, managed by forced hydrostatic dilatation of the cardia (20 patients-DILAT Group) or by esophagocardiomyotomy associated with esophagofundopexy (20 patients-Group OP) were followed-up for three years, in terms of clinical, radiographic, endoscopic, manometric and pH monitoring. RESULTS: 1) Both procedures can be performed without significant morbidity or mortality. 2) The two procedures are similar regarding ongoing suppression of dysphagia. 3) Radiologically, the methods are equivalent, since they promote significant elimination of contrast stasis and maintenance of the esophageal diameter. 4) Endoscopic follow-up did not differentiate the procedures in terms of the development of reflux esophagitis, with a rate of only 5% for each group of patients. 5) Manometry demonstrated that surgery produced a significantly greater reduction of the LESP as compared to dilatation, although the latter also determined a marked drop in the maximum basal pressure of the LES. 6) Neither procedure altered the length of the LES. 7) With prolonged esophageal pH monitoring, dilatation demonstrated a greater propensity for reflux as compared to surgery. CONCLUSION: Both methods offer benefits in the treatment of the initial stage of megaesophagus, although esophageal pH monitoring indicates that dilatation provokes a greater index of esophageal acid exposition time.

Esophageal tumor with an unusual histological appearance: a case report.

Year 1998
Manuc M. Oproiu C. Ionescu M. Popovici D. Dutu R. Popescu C. Gheorghe C. Oproiu A.
Center of Gastroenterology, Fundeni Clinical Hospital, Bucharest, Romania.
An unusual esophageal tumor in a 58-year-old man complaining of dysphagia and weight loss is herein described. Esophageal radioscopy and endoscopy visualized a huge polypoid tumor which was occluding the esophagus. After esophageal resection, the histological examination revealed miscellaneous benign cells (squamous, columnar fat cells, cartilaginous cells, and glandular structures) and two different malignant areas (spindler sarcomatous cells and squamous cells). There was no malignant invasion in the stalk, in the adjacent esophageal wall, or in the periesophageal tissue, and there were no malignant adenopathies. The postoperative course was favorable for one year, until the patient developed pain in the right superior back. A sarcomatous relapse was diagnosed by fine-needle biopsy under CT guidance, and the patient subsequently received radiation therapy.

Endoscopic resection of gastrointestinal submucosal tumors.

Year 1998
Wei SC. Wong JM. Shieh MJ. Sun CT. Wang CY. Wang TH.
Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan, R.O.C.
BACKGROUND/AIMS: The occurrence of submucosal tumors in the gastrointestinal tract is not infrequent. According to endoscopic pictures, submucosal tumors can usually be diagnosed without difficulty. However, even with the aid of endoscopic ultrasound, a definite diagnosis is not possible without histological results. Before endoscopy became available, the treatment strategy for gastrointestinal submucosal tumors was either surgery or observation. Due to advances in scientific technology, endoscopic treatment of gastrointestinal submucosal tumors has become increasingly popular. In reviewing the literature, we found that only case reports or small series reports detailing specific tumors in specific locations existed previously. METHODOLOGY: Endoscopic resection for 12 gastrointestinal submucosal tumors in 11 patients has been successfully performed in our hospital during the past three years. RESULTS: The group included 5 men and 6 women, ranging in age from 28 to 78 years. The locations of the tumors consisted of 1 in the esophagus, 2 in the stomach, 1 in the jejunum, 5 in the colon and 3 in the rectum. Histological results showed 3 lipomas, 3 carcinoids, 2 leiomyomas, 1 ganglioneuromatous polyp, 1 hemangioma, 1 inflammatory fibroid polyp and 1 myomatous hyperplasia. Bleeding complications occurred in only 2 cases. One stopped spontaneously and the other stopped after epinephrine and sclerosant injection. Only 1 case required a two-step resection in order to avoid perforation. No tumor recurrence was noted during the follow-up period, which ranged from 2 months to 3 years. CONCLUSIONS: In suitable cases, endoscopic resection of gastrointestinal submucosal tumors can be a safe and valuable method for treating symptomatic tumors and obtaining histological diagnosis of the submucosal tumors.

Does endoscopic hemostasis effect the reduction of mortality in patients with hemorrhage from the digestive tract?

Year 1998
Skok P.
Department of Gastroenterology and Endoscopy, Maribor Teaching Hospital, Slovenia.
BACKGROUND/AIMS: Endoscopy is the method of choice for localizing the sites of hemorrhage and transendoscopic hemostatic procedures in patients with hemorrhage from the digestive tract. The aim of the study was to establish the efficacy of endoscopic hemostasis and to analyze the mortality of patients with upper digestive tract hemorrhage. METHODOLOGY: The retrospective analysis included those patients who had undergone urgent endoscopic examination of the upper digestive tract and hemostatic interventions with injection sclerotherapy, laser photocoagulation or electrocoagulation of the hemorrhaging spot in the period between January 1994 and May 1995. RESULTS: 1000 patients were examined, 638 men and 362 women. In only 312 patients (31.2%) the examination revealed signs of acute or recent hemorrhage. Hemostatic interventions were performed in 275 (27.5%) cases. During hospitalization at the medical wards, 14 (9/275, 5.1%) patients died. In 9 patients (9/275, 3%) with acute hemorrhage, endoscopic hemostasis did not prove successful, therefore after several unsuccessfully repeated endoscopic interventions (21 in all), the patients were treated operatively. During the postoperative period, 4 patients died due to complications. CONCLUSIONS: Despite the development of endoscopic instruments and improved methods of hemostasis, mortality due to hemorrhage from the digestive tract has not dramatically decreased. Numerous demanding endoscopic procedures are usually carried out in older patients which also suffer from other diseases. These diseases represent the risk factors for eventual surgical treatment and the ensuing complications.

Intra-arterial infusion of octreotide to stop gastrointestinal tract bleeding that is difficult to manage surgically: a case report.

Year 1998
Chen HM. Jan YY. Chen MF.
Department of Surgery, Chang Gung Memorial Hospital, Taipei, Taiwan.
Intraluminal bleeding after gastrointestinal and bilopancreatic surgery continues to be a very difficult management problem. Herein, we report two cases of postoperative gastrointestinal bleeding which were successfully treated with intra-arterial infusion of octreotide. The two patients had undergone biliary tract surgery and experienced postoperative gastrointestinal bleeding. Abdominal angiography revealed extravasation from branches of the dorsal pancreatic artery and gastroduodenal artery in each patient, respectively. Transcatheter arterial embolization was performed, but without success in stopping the bleeding. The administration of octreotide via a regional arterial infusion finally stopped the bleeding in each of these two cases.

Monitoring of serum levels of HCV RNA in early phase of IFN therapy; as a predictive marker of subsequent response.

Year 1998
Yamakawa Y. Sata M. Suzuki H. Tanaka K. Tanaka E. Noguchi S. Ono K. Tanikawa K.
Kurume University School of Medicine, Kurume, Japan.
BACKGROUND/AIMS: To determine whether the initial response to interferon (IFN) therapy predicts the long-term response, monitoring of HCV RNA level in the early phase of IFN therapy was performed. METHODOLOGY: Sixty-seven patients with chronic hepatitis C virus (HCV) infection were investigated. Patients received 6 MU of human lymphoblastoid IFN daily for 2 weeks and then three times weekly for 22 weeks (total dose; 480 U). These were 34 complete responders (CR) and 33 non-responders (NR). Serum levels of HCV RNA were assayed before therapy and at weeks 1 and 2, using the AMPLICOR HCV Monitor kit. RESULTS: Serum levels of HCV RNA were below the detection limit in 33 (97.1%) of 34 CR compared with 13 (39.4%) of 33 NR at week 1, and in 100% of CR compared with 17 (51.5%) of NR at week 2 (P < P0.05). These observations were independent with viral genotypes. CONCLUSION: A complete response to IFN therapy results primarily from a rapid decrease in the serum levels of HCV RNA and a further decrease to below the detection limit by week 2 of the therapy. In spite of a viral genotype, early monitoring of serum levels of HCV RNA during IFN therapy are predictive of a subsequent long-term response to IFN in patients with chronic HCV infection.

Intrahepatic cholangiocarcinoma associated with hepatolithiasis.

Year 1998
Sato M. Watanabe Y. Ueda S. Ohno J. Kashu Y. Nezu K. Kawachi K.
Department of Surgery II, Ehime University School of Medicine, Japan.
BACKGROUND/AIMS: Despite sporadic reports of cholangiocarcinoma (CC) associated with hepatolithiasis, this entity has not been widely studied. The purpose of this study was to clarify its clinical features and optimal management by studying the 10 patients we have encountered with this condition. METHODOLOGY: There were six women and four men, with a mean age of 61 years. The patients underwent anatomic hepatic resection (n = 5) or biliary drainage (n = 5). The clinical features and results of surgery were studied. RESULTS: The characteristic findings included tumor-related symptoms, irregular ductal stricture or obstruction, and hepatic lobar atrophy with a whitish mass. The tumor and stones were located in the same hepatic lobe. Eight patients had advanced CC with periductal tumor infiltration, while two had in situ carcinoma characterized by intraductal tumor growth, papillary adenocarcinoma, and mucin-hypersecretion. Seven patients died within 6 months after surgery, while the remaining three, including the two with in situ carcinomas and one with an involved node at the dissected hilum, are alive more than 4 years after anatomic hepatic resection. CONCLUSIONS: Recognition of the clinical features of CC associated with hepatolithiasis, which were clarified in this study, is important in treating patients with hepatolithiasis. An anatomic hepatic resection with hilar nodal dissection offers long-term survival in selected patients.

Transmission of hepatitis C virus: a study of the main risk factors in a Sicilian population of volunteer blood donors.

Year 1998
Soresi M. Mazzola A. Carroccio A. Agliastroa R. Magliarisi C. Cassara A. Cartabellotta A. Bascone F. Montalto G.
Cattedra di Medicina Interna, Universita di Palermo.
BACKGROUND/AIMS: The Hepatitis C virus (HCV) is quite widespread in Sicily, and in the absence of a vaccine, prophylaxis is important. In order to determine the most effective means of prophylaxis, we must first understand the main vectors of transmission. METHODOLOGY: We performed a case control study on 274 consecutive anti-HCV virus positive subjects and compared them with 548 anti-HCV negative subjects, matched for sex and age and selected from voluntary blood donors. The modes of transmission were investigated by means of a detailed questionnaire focused on the common risk factors of HCV contagion. RESULTS: Univariate analysis showed associations between HCV infection and transfusions (OR 23.0), surgery (OR 2.2), family history of chronic liver disease (OR 4.54), and drug addiction (OR 5.74). Multiple logistic regression indicated that transfusions (p < 0.0001), surgery (p < 0.002), family history (p < 0.0001), drug addiction (p < 0.002) and alcohol consumption (p < 0.002) are related to the development of HCV infection. CONCLUSIONS: The modes of transmission of HCV in an endemic area of Sicily do not greatly differ from those in other Italian regions; the subjects at greatest risk were those who had received blood transfusions or underwent surgery, alcoholics, drug abusers and those with a family history of chronic liver disease, who are probably more exposed to contracting the infection by non-conventional ways of transmission.

Lidocaine elimination and monoethylglycinexylidide formation in patients with chronic hepatitis or cirrhosis.

Year 1998
Testa R. Campo N. Caglieris S. Risso D. Alvarez S. Arzani L. Giannini E. Lantieri PB. Celle G.
Department of Internal Medicine, University of Genoa, Italy.
BACKGROUND/AIMS: The aim of this study was to evaluate the relationship between plasma elimination of lidocaine and monoethylglycinexylidide (MEGX) formation, which is considered to be a quantitative liver function test. METHODOLOGY: The study included ten healthy subjects and 54 patients: 27 with chronic hepatitis and 27 with cirrhosis. Lidocaine and MEGX were measured at 0, 2, 5, 10, 15, 30 min and then every 30 min for 180 min using the TDX system. RESULTS: In cirrhotic patients, the lidocaine half-life of the slow decline phase of the plasma disappearance curve (beta-HL) and the lidocaine half-life of hepatic elimination from the second compartment (K20-HL) proved to be significantly abnormal, as did all parameters of MEGX formation. In chronic hepatitis, both the lidocaine kinetics and the MEGX formation parameters were within the normal range. In chronic hepatitis patients, MEGX formation (AUC 0-180) was significantly correlated to K20-HL (rs = -0.633, p < 0.001) and to the rapid decline phase of the plasma disappearance curve (alpha-HL, rs = -0.483, p < 0.05). In cirrhotic patients, MEGX was significantly correlated to K20-HL (rs = -0.423, p < 0.05) and to beta-HL (rs = -0.500, p < 0.01). CONCLUSIONS: These results show that in chronic active hepatitis, MEGX formation from lidocaine is maintained as a metabolic process, whereas it is altered in cirrhotic patients. The interrelationship between lidocaine elimination and MEGX formation were somewhat different in the two liver diseases.

Liver damage score--a new index for evaluation of the severity of chronic liver diseases.

Year 1998
Krastev Z.
Clinic of Gastroenterology, University Hospital St. Ivan Rilsky, Medical University, Sofia.
BACKGROUND/AIMS: Many hepatologists believe that the Child's classification is not the ultimate prognostic tool for liver disease. Our aim was to develop an index for the estimation of the severity of liver damage, to evaluate its predictive power for the short-term and long-term prognosis of patients with chronic liver disease, and for the estimation of the effect of different therapeutic regimens. METHODOLOGY: The Liver Damage Score (LDS) was developed based on the analysis of the laboratory data of 151 randomly selected patients with liver diseases. Variables for reduced protein synthesis, increased production of antibodies, cytolysis, cholestasis, functional renal failure were combined into LDS according to the results of cluster analysis. The evaluation of the liver injury was analyzed in 696 patients with different liver diseases. RESULTS: There are three groups of liver diseases: mild-with LDS of 1-2 U, moderate with LDS 3-4.5 U and severe with LDS > 5.0 U. There was a good correlation between the LDS and the scores for liver cirrhosis. Values above 4-6 U carry bad prognosis. The LDS truthfully reflects the evolution of liver diseases over time and the effect of therapy. CONCLUSION: The LDS is a new, simple, low-cost, biomathematically and pathophysiologically based index, useful for monitoring practically all patients with liver diseases, no matter what the etiology and stage of the liver injury is. It allows a quantitative expression of the disease severity and the improvement or deterioration in its course.

Preoperative selective portal vein embolizations are an effective means of extending the indications of major hepatectomy in the normal and injured liver.

Year 1998
Elias D. Debaere T. Roche A. Bonvallot S. Lasser P.
Department of Surgical Oncology, Institut Gustave Roussy, Comprehensive Anticancer Center, Villejuif, France.
BACKGROUND/AIMS: Liver tumors may be unresectable for volumetric reasons; the post-hepatectomy future remaining liver (FRL) will be too small to ensure survival. In some cases, preoperative selective portal vein embolization (PSPVE) of the tumorous part of the liver can permit the induction of hypertrophy of the FRL and convert patients from an unresectable to a resectable status. METHODOLOGY: Analysis of the efficiency of PSPVE in changing the volume of the FRL and in permitting curative hepatectomy was performed in a retrospective study of 28 initially unresectable (for volumetric reasons), consecutive cases treated from September 1987 to September 1995. Fifty percent of the cases had damaged liver parenchyma. PSPVE was performed in various locations, according to the site of the tumor and impairment of the liver parenchyma. RESULTS: Twenty-five PSPVE (89%) successfully induced sufficient hypertrophy of the FRL. Explanations could be found retrospectively for the 3 failures. For the 28 cases, the mean increase in the FRL was 70%, and the mean ratio between the FRL and the whole functional liver changed from 21.5% before PSPVE, to 33.9% after PSPVE. Twenty-three patients could be hepatectomized (82%). CONCLUSIONS: With this technique, liver tumors considered to be unresectable, due to life-threatening volumetric insufficiency, may be considered resectable lesions, and there is an increase in the safety of some extended hepatectomies. These good results were mainly due to application of the distal and proximal free flow embolization technique, with non-absorbable material, and perhaps to the long interval of one month between PSPVE and hepatectomy. Indications in normal liver parenchyma are for patients with a very small left lobe or those requiring a right hepatectomy with wedge resections of the left liver. Indications for damaged liver parenchyma also include some cases requiring left trisegmentectomy or central hepatectomy.

Operative risks of major hepatic resections.

Year 1998
Capussotti L. Polastri R.
Ospedale Mauriziano Umberto I, Department of Surgery, Turin, Italy.
BACKGROUND/AIMS: Despite recent advances in liver surgery, major hepatic resection still remains a major operation with significant mortality and morbidity. We report our experience with major hepatic resections with particular regard to the operative risk of this procedure in cirrhotic and non-cirrhotic patients. METHODOLOGY: One hundred and ninety-three patients with malignant (77.2%) or benign (22.8%) liver tumors underwent major hepatic resection between January 1981 and December 1995. Twenty-eight patients had cirrhosis. We performed 109 right hepatectomies (56.5%), 30 right extended hepatectomies (15.5%), 32 left hepatectomies (16.6%), 15 left extended hepatectomies (7.8%) and 7 trisegmentectomies (3.6%). In 63 patients (32.6%), single or multiple associated resections were performed. Selected intraoperative and outcome data were compared in this retrospective analysis. RESULTS: There were 9 intraoperative complications: 4 injuries of the contralateral biliary duct, 4 injuries of the vena cava and 1 partial stricture of the left hepatic vein. The mean operation time was 284 +/- 97.9 min. The mean number of transfused units of blood was 1.6 +/- 1.8. The patients with operative complications required a median of 5 units of blood (range: 1-11) (p = 0.001). The intra- and postoperative mortality was 3.1%. Seventy-six patients (39.3%) developed postoperative complications, and 20.7% of these were major complications. Blood replacement was significantly higher in the cirrhotic patients (p = 0.007). No other significant differences were found between the cirrhotic and non-cirrhotic patients. CONCLUSIONS: Major hepatic resection for malignant or benign disease can be performed safely with minimal morbidity and mortality in patients with normal livers and in selected cirrhotic patients classified as Pugh A.

Recurrent liver failure with severe rhabdomyolysis after liver transplantation for carbon tetrachloride intoxication.

Year 1998
Nehoda H. Wieser C. Koller J. Konigsrainer A. Battista HJ. Vogel W. Margreiter R.
Dept. of Transplant Surgery, University Hospital Innsbruck, Austria.
Acute liver failure due to intoxication is a rare indication for liver transplantation which a usually has a good prognosis. We herein report the case of a young male, who underwent orthotopic liver transplantation for acute liver failure due to carbon tetrachloride intoxication. Apart from hepatic and renal failure, the patient also developed severe rhabdomyolysis, which has not thus far been described as a toxic effect of this chemical agent. Despite forced hyperventilation, which is known to be the most effective means of eliminating the specifically lipophylic agent, as well as excessive plasma exchange following intravenous administration of fat emulsions, liver failure recurred when blood carbon tetrachloride concentrations were already at non-toxic levels. Retransplantation of the liver together with a kidney was only temporarily successful, since the patient died due to aspergillus sepsis. Based on this experience, we would recommend that whenever possible in patients with carbon tetrachloride intoxication, liver transplant should be delayed until most of the toxic agent has been eliminated in order to prevent fatal graft damage.

Serum-soluble interleukin-2 receptor in patients with hepatolithiasis: a preliminary report.

Year 1998
Sheen-Chen SM. Eng HL. Chou FF. Chen WJ.
Department of Surgery, Pathology, and Diagnostic Radiology, Chang Gung Memorial Hospital, Kaohsiung, Chang Gung Medical College, Taiwan.
BACKGROUND/AIMS: Hepatolithiasis is prevalent in Southeast Asia and remains a difficult problem to manage. Recent studies in immunology have provided evidence for the provocative roles of cytokines in many diseases. This study was designed to explore the possible relationship between the serum-soluble interleukin-2 receptor and the pathogenesis of hepatolithiasis. METHODOLOGY: In this pilot study, 34 patients with hepatolithiasis were included. All of the patients met the following criteria: (1) presence of hepatolithiasis; (2) no obvious clinical evidence of associated intrahepatic cholangiocarcinoma; (3) no clinical manifestation of cholangitis for at least 72 hours; (4) no intake of immunomodulatory agents in the previous 3 weeks; and (5) no blood transfusions in the previous 3 weeks. Venous blood samples were collected before surgery, and the concentrations of serum soluble interleukin-2 receptor were measured with an enzyme immunoassay method. Fifteen healthy subjects were used as the control group. Bile specimens routinely obtained during surgery were cultured for aerobes and anaerobes. The cholangiography films were reviewed in detail. RESULTS: The mean value of soluble interleukin-2 receptor in patients with hepatolithiasis was 706 +/- 294 units/ml, and that of the control group was 326 +/- 62 units/ml. The difference was significant (p < 0.01). Bacteria were present in the bile of all patients. The total number of bacterial species in the 34 patients was 119, and there was an average of 3.5 bacterial species cultured per patient. Intrahepatic bile duct strictures were present in 30 patients (88%). CONCLUSIONS: In addition to a high incidence of intrahepatic bile duct strictures and bacterial infection of the bile, significantly high levels of the serum soluble interleukin-2 receptor were also found in the patients with hepatolithiasis. The preliminary results in the present study seem to be promising, and the specific role of the soluble interleukin-2 receptor in patients with hepatolithiasis deserves further investigation and elucidation.

Hepatic metastasis from esophageal cancer treated by surgical resection and hepatic arterial infusion chemotherapy.

Year 1998
Hanazaki K. Kuroda T. Wakabayashi M. Sodeyama H. Yokoyama S. Kusama J.
Department of Surgery, Nagano Red Cross Hospital, Japan.
We herein describe a successful surgical resection of esophageal cancer with syncronous liver metastasis and report the first case of a partial response to hepatic arterial infusion chemotherapy for recurrence of esophageal hepatic metastasis after hepatectomy. Hepatectomy and subsequent hepatic arterial infusion chemotherapy with cisplatin and 5-fluorouracil is thus recommended as an effective treatment for liver metastasis from esophageal cancer.

Catheter seeding of hepatocellular carcinoma following placement of a total implantable access port system.

Year 1998
Alessiani M. Vai L. Jemos V. Dionigi P. Spada M. Porta C. Moroni M. Nastasi G. Fossati GS. Zonta A.
Department of Surgery and Medical Therapeutics, University of Pavia, Italy.
A 61-year-old cirrhotic patient underwent hepatic resection for hepatocellular carcinoma and placement of a total implantable access port system in the hepatic artery for chemotherapy infusion. A year later, he developed a parietal metastasis at the port site as a consequence of tumor seeding along the arterial catheter. The metastasis was excised but the patient died because of disseminated disease two years after the first operation. Tumor seeding along the catheter should be included in the group of potential complications after placement of total implantable access port systems for intrahepatic chemotherapy The possible causes of this rare but life-threatening complication are discussed.

Alpha-1-thymosin and transcatheter arterial chemoembolization in hepatocellular carcinoma patients: a preliminary experience.

Year 1998
Stefanini GF. Foschi FG. Castelli E. Marsigli L. Biselli M. Mucci F. Bernardi M. Van Thiel DH. Gasbarrini G.
Divisione di Medicina Interna, Ospedale di Faenza, Ra.
BACKGROUND/AIMS: To evaluate the tolerability and therapeutic potential of the immunostimulating adjuvant alpha-1-thymosin in patients with hepatocellular carcinoma. METHODOLOGY: Twelve patients with hepatocellular carcinoma were treated with alpha-1-thymosin (900 micrograms/m2 subcutaneously twice per week for 6 months) and transcatheter arterial chemoembolization and compared to a historical control group (matched for gender, age, Okuda staging, Child's score, alpha-fetoprotein serum levels and viral infection) treated with transcatheter arterial chemoembolization alone. RESULTS: No severe side effects were recorded in the 2 treatment groups. The combination of alpha-1-thymosin plus transcatheter arterial chemoembolization resulted in a longer survival that reached statistical significance 7 months after the end of treatment (p < 0.05). Patients receiving combined treatment demonstrated a significant increase in peripheral blood mononuclear cells expressing CD3 (p < 0.05) and CD8 (p < 0.025) 3 months after beginning treatment. They also had a significant increase (p < 0.05) in CD16+ and CD56+ cells after 1 month, and a slight reduction in mononuclear cells expressing CD25, a marker for cell activation. No alterations in the response to phytohemagglutinin stimulation were seen during the alpha-1-thymosin treatment. CONCLUSIONS: The absence of toxicity and the favourable effects observed in this open study call for a double blind control study to confirm the efficacy of the combined treatment.

Virus-associated hemophagocytic syndrome after hepatic resection: a case report.

Year 1998
Hasegawa H. Takenaka K. Kajiyama K. Shirabe K. Shimada M. Gondo H. Sugimachi K.
Department of Surgery II, Faculty of Medicine, Kyushu University, Japan.
Virus-associated hemophagocytic syndrome (VAHS) is associated with a systemic viral infection and is mainly observed in immunosuppressed adult patients. This rare disease is characterized by symptoms which include a high fever, pancytopenia, and splenomegaly and sometimes results in a fatal outcome. However, thus far, little has been reported on VAHS in general surgical patients. We herein report this rare complication which occurred in a patient with hepatocellular carcinoma, as well as chronic hepatitis C, after a hepatic resection. A 66-year-old man with chronic hepatitis C and recurrent hepatocellular carcinoma underwent a repeat hepatic resection without any blood transfusions. In the early postoperative period, he recovered uneventfully. However, he suddenly began to suffer from a high fever (38.4 degrees C) and severe pancytopenia 8 days after surgery. Activated macrophages, which phagocytosed erythrocytes, were identified by a cytological study of the bone marrow. The patient was therefore treated with methylprednisolone pulse therapy 13 days after surgery. On the day following the initial administration of methylprednisolone, his clinical condition drastically improved. Fortunately, with methylprednisolone therapy, our patient recovered from acute, severe pancytopenia. In general surgery, it is often difficult for surgeons to use steroids due to their negative side effects. However, when symptoms such as fever, general fatigue and pancytopenia are observed, even in posthepatectomy patients with hepatocellular carcinoma and hepatitis, a bone marrow aspiration should be performed as soon as possible, and when VAHS is suspected, steroid pulse therapy should be the first treatment of choice. This rare but sometimes fatal complication should thus be taken into consideration in the postoperative management of hepatectomized patients with chronic hepatitis C.

Minute mixed hepatoma with two components: hepatocellular and cholangiocarcinoma, which developed on liver cirrhosis with HCV.

Year 1998
Tanaka T. Imamura A. Hayashi S. Tsuruta K. Igari T. Koike M. Tanaka S.
Liver Unit, Tokyo Metropolitan Komagome Hospital, Japan.
Mixed type hepatoma with two components, hepatocellular and cholangiocellular carcinoma, is very rare. We encountered a case of a single and minute mixed type hepatoma developing on liver cirrhosis in a patient with persistent hepatitis C viral infection. Histologically, the two-type cancer tissue existed in a nodule with a maximal diameter of approximately 20 mm, and the cholangiocellular carcinoma occupied about 70% of the tumor. The original cell of the mixed type hepatoma is unknown, but this case suggests that a bipotential cell developing into hepatocellular and cholangiocellular carcinoma may be the origin.

Hemorrhage caused by ruptured liver cell adenoma following long-term oral contraceptives: a case report.

Year 1998
Meissner K.
Department of Surgery, District General Hospital, Austria.
A 41-year-old woman who had taken oral contraceptives for 14 years was admitted to the hospital with pain in the left shoulder region and epigastrium arising after regurgitation. Sonography and CT revealed a ruptured liver tumor with sealed-off liver hemorrhage. The resected specimen revealed a ruptured and partially necrotic liver cell adenoma. This paradigmatic case illustrates a rare but well known entity: liver cell adenomas prone to necrosis and hemorrhage, requiring emergency intervention, in women on long-term oral contraceptive therapy.

Potentiality of dissection of the lymph nodes with preservation of the nerve plexus around the superior mesenteric artery.

Year 1998
Kawabata A. Hamanaka Y. Suzuki T.
Department of Surgery II, Yamaguchi University School of Medicine, Japan.
BACKGROUND/AIMS: Periampullary cancer frequently metastasizes to the lymph nodes around the superior mesenteric artery. Simultaneous dissection of the nerve plexus around the SMA, however, often results in intractable diarrhea. This study was performed to examine the extent to which regional lymph nodes may be dissected while preserving the superior mesenteric nerve plexus during radical surgery for periampullary cancer. METHODOLOGY: The pancreas and surrounding tissue from ten adult autopsied subjects were sectioned at 5 mm intervals. The structure of the nerve plexus and the distribution of the lymph nodes were analyzed, and the anatomical relationship between the nodes and the nerve plexus was investigated. RESULTS: The average thickness of the PLsma was 4.2 +/- 1.3 mm, becoming thinner from the root to the periphery. The lymph nodes were distributed uniformly on the right and left hemicircles of the superior mesenteric artery and along its longitudinal axis. The average number of lymph nodes was 14.2 +/- 7.5 per subject, and the average maximum node diameter was 3.3 +/- 2.3 mm. The distance from the adventitia of the superior mesenteric artery to the node was 5.5 +/- 2.0 mm. Of a total of 142 lymph nodes, 134 (94.4%) were located outside of the nerve plexus. CONCLUSION: Dissection of the superior mesenteric lymph nodes while preserving the superior mesenteric nerve plexus is theoretically possible.

Pancreatic resection for periampullary cancer in elderly patients.

Year 1998
Magistrelli P. Masetti R. Coppola R. Riccioni ME. Crucitti A. Nuzzo G. Picciocchi A.
Department of Surgery, Catholic University of Rome, Italy.
BACKGROUND/AIMS: Major abdominal surgery in elderly patients has traditionally been thought to carry a high operative risk. Recent data, however, have suggested that with proper selection, elderly patients can withstand pancreatic resection. METHODOLOGY: The medical records of 102 patients who underwent pancreatic resection for pancreatic or periampullary tumors were retrospectively reviewed. Twenty-nine patients were aged 70 years or older (mean age: 74 years) and 73 patients were younger (mean age: 56 years). Concomitant comorbid conditions were evaluated in the patients of both groups, and no significant differences were identified. A pancreaticoduodenectomy was performed in 81 cases and a total pancreatectomy in 21. RESULTS: The operative mortality rate was 0% in the older patients and 6.8% in the younger patients. Major complications occurred in 28% of the patients. There were no significant differences in morbidity among the two age groups. The overall actuarial survival curves showed similar trends in both groups. CONCLUSIONS: With appropriate preoperative selection, pancreatic resection can be performed with low operative risk in elderly patients. Chronological age alone should not be considered an absolute contraindication for pancreatic resection.

The effect of octreotide on the prevention of acute pancreatitis and hyperamylasemia after diagnostic and therapeutic ERCP.

Year 1998
Arvanitidis D. Hatzipanayiotis J. Koutsounopoulos G. Frangou E.
Department of Gastroenterology, 251 Hellenic Air Force Hospital, Athens, Greece.
BACKGROUND/AIMS: Acute pancreatitis is a serious complication of diagnostic and therapeutic Endoscopic Retrograde Cholangiopancreatography (ERCP). In addition, serum pancreatic enzymes increase without symptoms in about 40-50% of patients undergoing these endoscopic procedures. In order to evaluate the efficacy of octreotide in the prevention of these complications, we performed this randomised, prospective study. METHODOLOGY: We studied 73 patients (31 males, 42 females), mean age 63.3 +/- 12.9 years (range 28-87 yrs). The patients were randomly allocated into two groups (A and B). Group A (37 patients) was given 0.1 mg of octreotide subcutaneously 30 min before and 8 and 16 hours after the procedure, and group B (36 patients) was given a placebo. Serum amylase was measured 30 min before and 3 and 6 hrs after ERCP. All patients were subjected to ultrasonography for signs of pancreatic inflammation. There was no statistically significant difference between the two groups concerning age, sex and indication for ERCP. Endoscopic sphincterotomy (ES) was performed in 14 patients of group A and 10 patients of group B. RESULTS: There were 4 cases of acute pancreatitis in each group and the mean serum amylase at 3 and 6 hrs was comparable (494/676 and 429/582 IU/L, respectively). In comparing patients who were subjected to either diagnostic or therapeutic ERCP, there was no statistically significant difference concerning episodes of acute pancreatitis and the level of serum amylase. CONCLUSION: Octreotide does not seem to prevent acute pancreatitis and hyperamylasaemia after diagnostic and therapeutic ERCP.

Prognostic value of CA 19-9 serum course in pancreatic cancer.

Year 1998
Safi F. Schlosser W. Falkenreck S. Beger HG.
University Hospital of Ulm, Department of General Surgery, Germany.
BACKGROUND/AIMS: The aim of this study was to determine the sensibility and specificity of a new assay in the diagnosis of pancreatic cancer and predictability of resection rates. In addition, the serum CA19-9 levels was utilised as a prognostic indicator. METHODOLOGY: Serum expression of the tumor marker CA 19-9 was studied in 2119 patients. RESULTS: The discriminating capacity of CA 19-9 between benign and malignant disease was high, especially in patients with pancreatic cancer (n = 347). The sensitivity of CA 19-9 was 85%. In patients who were Lewis blood type positive, the sensitivity increased to 92%. The CA 19-9 levels were significantly lower in patients with resectable tumors (n = 126) than in those with unresectable tumors (n = 221, p < 0.0001) (sensitivity 74% versus 90%). The CA 19-9 levels dropped sharply after resection but normalized only in 29%, 13%, and 10% of patients with stage I, II, and III, respectively. In unresectable tumors, no significant decrease in CA 19-9 levels after laparotomy or bypass was found. Among patients with the same tumor stage, the median survival time of those whose CA 19-9 levels returned to normal after resection was significantly longer than those with postoperative CA 19-9 levels that decreased but did not return to normal (stage I: 33 versus 11.3 months; stage II: 41 versus 8.6 months; stage III: 28 versus 10.8 months). In patients with recurrent disease, 88% had an obvious rise in CA 19-9 levels. CONCLUSION: CA 19-9 measurement is a simple test which can be used for diagnostic purposes, as well as the prediction of resectability, survival rate after surgery, and the potential for recurrence.

Surgery for gastric cancer in patients older than 80 years of age.

Year 1998
Hanazaki K. Wakabayashi M. Sodeyama H. Miyazawa M. Yokoyama S. Sode Y. Kawamura N. Ohtsuka M. Miyazaki T.
Department of Surgery, Nagano Red Cross Hospital, Nagano, Japan.
BACKGROUND/AIMS: Although the number of elderly patients who undergo surgery for gastric cancer has increased in recent years, the clinical features associated with this group of patients, including their postoperative survival rate, remain unclear. METHODOLOGY: The cases of 50 patients > or = 80 years of age (the older group) with gastric cancer who underwent surgical treatment in our Department from January 1988 to December 1995 were reviewed and compared to the records of 239 patients < or = 60 years of age (the younger group) who had surgery during the same time period. RESULTS: The incidence of advanced gastric cancer in the older versus younger groups was 59.6% versus 27.9%, respectively (p < 0.01). The tumor size was significantly larger in the older group. The tumor location in the older group predominantly involved the upper third of the stomach, while in the younger group, the middle third of the stomach was primarily involved. Histologically, the incidence of differentiated tumor types was 65.1% versus 50.5% (p < 0.05), and undifferentiated types, 34.9% versus 49.5% (p < 0.05), in the older and younger groups, respectively. Retrospective comparisons conducted between the older and younger groups revealed the following: curative resectability rate: 52.0% versus 74.5% (p < 0.01); hospital mortality rate: 2% versus 0%; overall 5-year survival rate: 46.1% versus 71.1% (p < 0.01); and a 5-year survival rate in patients who underwent curative resection of 65.0% versus 88.8% in the older versus younger age groups, respectively. CONCLUSIONS: These results suggest that the survival of elderly patients with gastric cancer is worse than that of younger patients because of a lower curative resection rate of the advanced cancer. However, the survival rate in elderly patients is identical to that in younger patients if a curative resection is performed.

Effect of the H2 histamine receptor antagonist on oxygen metabolism in some morphotic blood elements in patients with ulcer disease.

Year 1998
Kedziora-Kornatowska K. Tkaczewski W. Blaszczyk J. Buczynski A. Chojnacki J. Kedziora J.
Department of Gastroenterology, Military Medical University, Lodz, Poland.
BACKGROUND/AIMS: Our investigations was carried out in order to examine the effect of cimetidine, ranitidine and famotidine on the generation of free radicals, lipid peroxidation and enzymatic antioxidative defense in the blood of patients with peptic ulcer disease, clinically diagnosed as gastric or duodenal ulcer. METHODOLOGY: 124 non-smoking males (aged 20-51 years), were randomly divided into 4 groups: 28 patients received intravenously 200 mg of cimetidine; 26 patients intravenously 50 mg comprised of ranitidine; 25 patients received intravenously 20 mg of famotidine; and 45 healthy men served as the control group. Superoxide dismutase activity, malonyldialdehyde concentration in blood platelets and superoxide anion generation in granulocytes were determined in all examined men. An assay of superoxide dismutase activity and malonyldialdehyde concentration were performed before drug administration and after 2 and 72 hours. Superoxide anion generation was estimated before drug administration and after 2 hours. RESULTS: Our data indicate that all examined H2 receptor antagonists stimulate superoxide dismutase activity, but after 72 hours a distinct increase was observed, in addition to a decrease of malonyldialdehyde concentration. No differences have been observed in superoxide anion generation in patients with ulcer disease or in healthy subjects before and after ranitidine and famotidine administration. Only after 2 hours of cimetidine administration was a significant increase in superoxide anion generation observed. CONCLUSION: We concluded that H2 receptor antagonists have a beneficial effect on antioxidative processes.

Lymph node metastasis in gastric cancer in the upper third of the stomach--surgical treatment on the basis of the anatomical distribution of positive node.

Year 1998
Kitamura K. Nishida S. Yamamoto K. Ichikawa D. Okamoto K. Taniguchi H. Yamaguchi T. Sawai K. Takahashi T.
First Department of Surgery, Kyoto Prefectural University od Medicine, Japan.
BACKGROUND/AIMS: Little is known about the most appropriate surgical procedure for gastric cancer in the upper third of the stomach. The objective of this study was to determine the most appropriate surgical treatment for gastric cancer in the upper third of the stomach. METHODOLOGY: The clinicopathological characteristics of 115 node-positive gastric cancers in the upper third of the stomach were reviewed retrospectively and compared with those of 111 node-negative gastric cancers in the upper third of the stomach. RESULTS: Node-positive gastric cancers showed higher rates of peritoneal metastasis (p < 0.005), larger tumor sizes (p < 0.005), deeper tumor penetration (p < 0.005), higher rates of diffuse type in histology (p < 0.025), and more advanced histological stages (p < 0.005), than node-negative gastric cancers. Patients with node-positive gastric cancer demonstrated a poorer survival rate than those with node-negative gastric cancer (p < 0.005). Lymph node metastasis along the lower stomach was observed in cases of gastric cancer which had invaded beyond the muscularis propria of the stomach but not in those confined within the muscularis propria. No lymph node metastasis in the splenic hilum was found in association with gastric cancer when the depth was limited to the mucosa or the submucosa. CONCLUSION: The appropriate surgical procedures for the treatment of gastric cancer in the upper third of the stomach are as follows: a) proximal gastrectomy without splenectomy for gastric cancer when the depth is limited to the mucosa or the submucosa, b) proximal gastrectomy with splenectomy for gastric cancer when the depth of invasion extends to the muscularis propria, c) total gastrectomy with splenectomy for gastric cancer when the depth of invasion extends beyond the muscularis propria.

Laparoscopic repair of a paraesophageal hiatal hernia with gastric volvulus.

Year 1998
Kuwano H. Hashizume M. Ohta M. Sumiyoshi K. Sugimachi K. Haraguchi Y.
Department of Surgery II, Faculty of Medicine Kyushu University, Fukuoka, Japan.
We report the case of a massive paraesophageal hiatal hernia with gastric volvulus which presented with the symptom of a precordial sense of pressure for over two years, which was successfully treated with laparoscopic surgery. The patient is presently in good condition, without any recurrence of either the hiatal hernia or other symptoms one year after surgery. This approach is considered to be a safe and effective procedure, and it also provides for rapid recovery from the operation.