Combination of preoperative embolization of the right portal vein and hepatic artery prior to major hepatectomy in high-risk patients: a preliminary report

BACKGROUND/AIMS: Preoperative transhepatic portal vein embolization may not always be sufficient to achieve the desired changes in contralateral hepatic volume and function. The beneficial role of additional transcatheter arterial embolization performed after inadequate response to preoperative transhepatic portal vein embolization is described. METHODOLOGY: Four patients underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization, and 6 control patients underwent preoperative transhepatic portal vein embolization only. Changes in right liver lobe volume fraction, residual left lobe volume fraction, and prediction score (low-risk, < 45; borderline, 45-55; high-risk > 55); were evaluated. RESULTS: 1) The change in right liver lobe volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 0.75 times that of the original level whereas after preoperative transhepatic portal vein embolization, they were only 0.81 times that of the original level. 2) The change in residual left liver volume after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (volume after/before) was 1.40 times that of the original level whereas after preoperative transhepatic portal vein embolization they were only 1.30 times than the original level. The changes in left liver volume after preoperative transhepatic portal vein embolization/transcatheter arterial embolization was more favorable than those after preoperative transhepatic portal vein embolization only. 3) The change in prediction score after both preoperative transhepatic portal vein embolization and transcatheter arterial embolization (after/before) was 0.81 times that of the original level. All prediction score in high-risk patients recovered to the borderline or safety zone. Change after preoperative transhepatic portal vein embolization only (before/after) was 0.87 times that of the original level. 4) All 4 patients who underwent both preoperative transhepatic portal vein embolization and transcatheter arterial embolization received right hepatic lobectomy successfully and returned to their normal life style. CONCLUSIONS: Preoperative occlusion of right hepatic inflow vessels increased the volume and function of the contralateral lobe where high-risk patients recovered to the borderline zone for major hepatic resection.     

On-pump versus off-pump coronary artery bypass using quadruple arterial grafts

The optimal combination of arterial grafts for quadruple coronary artery bypass is the bilateral internal mammary artery, the radial artery, and the gastroepiploic artery. Patients who underwent quadruple bypass in our hospital group between December 1995 and March 2001 were retrospectively analyzed to determine whether off-pump surgery (n = 27) provides better outcomes than conventional on-pump surgery (n = 51). Preoperative risk factors as well as the mean number of distal anastomoses (4.5 in the off-pump versus 4.8 in the on-pump patients) were not significantly different between the 2 groups. Postoperative recovery was significantly faster in the off-pump group than in the on-pump group (intubation time, 6.4 versus 16 hours; stay in intensive care unit, 2 versus 3 days; and postoperative hospital stay, 12.3 versus 15.8 days). Early stenosis-free graft patency rates did not differ significantly (90.3% versus 89.3%). No late cardiac events were observed in the off-pump group, while 4 occurred in the on-pump group. Quadruple arterial bypass without cardiopulmonary bypass is safe, and it allows faster recovery. The follow-up results of off-pump patients so far have been satisfactory.     

Flowcharts for the management of biliary tract and ampullary carcinomas

No strategies for the diagnosis and treatment of biliary tract carcinoma have been clearly described. We developed flowcharts for the diagnosis and treatment of biliary tract carcinoma on the basis of the best clinical evidence. Risk factors for bile duct carcinoma are a dilated type of pancreaticobiliary maljunction (PBM) and primary sclerosing cholangitis. A nondilated type of PBM is a risk factor for gallbladder carcinoma. Symptoms that may indicate biliary tract carcinoma are jaundice and pain in the upper right area of the abdomen. The first step of diagnosis is to carry out blood biochemistry tests and ultrasonography (US) of the abdomen. The second step of diagnosis is to find the local extension of the carcinoma by means of computed tomography (CT), magnetic resonance imaging (MRI), magnetic resonance cholangiopancreatography (MRCP), percutaneous transhepatic cholangiography (PTC), and endoscopic retrograde cholangiopancreatography (ERCP). Because resection is the only way to completely cure biliary tract carcinoma, the indications for resection are determined first. In patients with resectable disease, the indications for biliary drainage or portal vein embolization (PVE) are checked. In those with nonresectable disease, biliary stenting, chemotherapy, radiotherapy, and/or best supportive care is selected.     

Hepatic venous outflow obstruction after right lateral sector living-donor liver transplantation,treated by insertion of an expandable metallic stent

Hepatic venous outflow obstruction is a relatively uncommon but important and devastating complication occurring after liver transplantation. Recently, right lateral sector liver grafts have sometimes been used in living-donor liver transplantation (LDLT), but, to our knowledge, early hepatic venous outflow obstruction has never been reported in right lateral sector LDLT. A 58-year-old woman was diagnosed with liver cirrhosis and hepatocellular carcinoma and underwent right lateral sector LDLT. Postoperatively, she developed liver dysfunction. Doppler ultrasound examination revealed flat waveforms and low-flow velocity in the right hepatic vein (RHV). A computed tomography (CT) scan revealed a ventrally distorted RHV due to hypertrophy of the liver graft. Hepatic venous obstruction was suspected and a hepatic venogram was performed. The venogram revealed stenosis of the RHV due to the distortion of the vein. We performed percutaneous transfemoral balloon dilatation, but this was not effective. We then inserted an expandable metallic stent (EMS) into the RHV. After the EMS placement, the condition of the patient improved. Venogram and CT data suggested that the obstruction of the RHV developed because of distortion of the RHV to the ventral side during liver regeneration.     

Patient satisfaction with sedation for flexible bronchoscopy

Background and objective:   Patient satisfaction with health care has increasingly been recognized as an important health outcome, but few studies have examined patient satisfaction with flexible bronchoscopy (FB). The purpose of this study was to assess patient satisfaction with FB conducted under conscious sedation and to identify the aspects of the procedure related to patient satisfaction.
Methods:   Patients' willingness to return for repeat FB was measured on a 5-point scale. Patients were asked whether they were bothered by the anaesthetic spray, scope insertion, shortness of breath, coughing, pharyngeal pain, chest pain or swallowing pain. Patients were asked to assess the quality of the physician, the institution and nursing, and their satisfaction with the privacy, waiting time and information provided about the procedure.
Results:   Of 161 consecutive eligible patients who underwent FB, 129 (80.1%) completed the questionnaire. Of the 129 patients, 65.8% reported that they would return for a repeat FB (12.4% would definitely return and 53.4% would probably return). Male gender, shorter examination time, excellent physician quality and not being bothered by coughing, pharyngeal pain or swallowing pain were related to greater patient satisfaction. The results of multiple logistic regression analysis showed that male gender was related to greater patient satisfaction.
Conclusions:   Bronchoscopists should try to recognize the factors that influence patient satisfaction and adjust their management accordingly.     

Skeletonized Radial Artery: New Technique for Graft Harvest with Improved Angiographic Results

To improve the patency rate of radial artery grafts, we have been using a skeletonized harvesting technique since September 2000. Our early reports confirmed better graft patency of skeletonized radial graft compared to conventional pedicled grafts. We present the angiographic and clinical follow-up data on skeletonized radial artery grafting. Between 09/01/2000 and 7/31/2002, a total of 268 patients underwent isolated coronary artery bypass using skeletonized radial artery graft, excluding T-grafting. Of these, 216 (80.6%) patients underwent postoperative angiography and their perioperative, early angiographic, and follow-up results were analyzed. There was 1 hospital death and 6 incidences of postoperative myocardial infarction. None were related to radial artery bypass. Early angiographic control revealed that the stenosis-free graft patency rate of radial artery anastomoses (318/331, 96.1%) was not significantly different from other conduits (the left internal mammary artery 93.5%, right internal mammary artery 90.8%, gastroepiploic artery 96.3%, and saphenous vein 97.6%). Follow-up was completed for all hospital survivors with a mean follow-up of 1.6 ± 0.4 years. There were no cardiac deaths, and 9 cardiac events, giving a cardiac event-free rate of 95.8%. The angiographical patency of the skeletonized radial artery was excellent. Although cardiac events were minimal, follow-up mid-term angiographics will be necessary to confirm our clinical outcome data.     

Self-reported rate of eating correlates with body mass index in 18-y-old Japanese women

OBJECTIVE: To examine associations between rate of eating and macronutrient and dietary fiber intake, and body mass index (BMI). DESIGN: Cross-sectional study. SUBJECTS: A total of 1695 18-y-old female Japanese dietetic students. MEASUREMENTS: Macronutrient intake (protein, carbohydrate, and fat) and dietary fiber intake were assessed over a 1-month period with a validated, self-administered, diet history questionnaire. Body height and weight and rate of eating (according to five categories) were self-reported. RESULTS: Among the nutrients examined, only dietary fiber intake weakly, but significantly, and negatively correlated with BMI in a multiple regression analysis. The rate of eating showed a significant and positive correlation with BMI. The mean BMI was higher by 2.2, 1.5, 1.0, and 0.5 kg/m(2) in the 'very fast', 'relatively fast', 'medium', and 'relatively slow' groups, respectively, compared with the 'very slow' rate of eating group. This correlation remained evident after adjustment for nutrient intake. CONCLUSIONS: Rate of eating showed a significant and positive correlation with BMI, whereas only dietary fiber intake showed a weak correlation with BMI.     

Antisense Bcl-x oligonucleotide induces apoptosis and prevents arterial neointimal formation in murine cardiac allografts

OBJECTIVE: Cardiac allograft arteriosclerosis, which limits long-term survival of recipients, cannot be prevented by conservative therapies. The arteriopathy is characterized by diffuse intimal thickening comprised of proliferative smooth muscle cells (SMCs). Cell death is a prominent feature of atherosclerosis; Bcl-x is one of the anti-apoptotic mediators. METHODS: To test the hypothesis that antisense bcl-x oligodeoxynucleotide (ODN) is effective in preventing intimal hyperplasia through enhancing apoptosis after cardiac transplantation, we performed single intraluminal delivery of antisense bcl-x ODN into murine cardiac allografts (n = 9). DBA/2 (H-2d) hearts were transplanted into B10.D2 (H-2d) mice. Sense bcl-x ODN (n = 8) and no treatment (n = 8) studies were also performed. RESULTS: Allografts were harvested at 4 weeks after transplantation; all allografts kept beating throughout the period. Coronary intimal thickening had developed in nontreated and sense ODN transfected allografts at 4 weeks after transplantation with enhanced expression of Bcl-x and cell adhesion molecules, and suppressed apoptosis. However, antisense bcl-x ODN prevented neointimal formation through enhanced apoptosis. CONCLUSION: These results indicate that apoptosis of vascular SMCs induced by Bcl-x is associated with initial hyperplasia after heart transplantation. Antisense bcl-x ODN inhibits SMC proliferation by inducing apoptosis in graft coronary arteries.