Where we go with hepatocellular carcinoma: past,present, and future perspectives

Background/Purpose: This article reviews past and current studies of hepacellular carcinoma (HCC), current investigations, the direction of research on HCC, and future perspectives. Methods: The discussion is based mainly on a survery of the literature and the author's experiences with patients. Results: Capability for diagnosing premalignant lesions is very limited, and methods are needed to predict the nature of hepatic nodules and diagnose early HCC. Current practice is far from satisfactory. Diagnosis of early HCC should not depend on H&E staining alone. More molecular information should be obtained for diagnosing early lesions. Conclusions: Prevention is the only way to reduce the number of HCC patients. There are four steps for prevention which require further attention and improvement. Received: March 20, 2002 / Accepted: April 15, 2002 Offprint requests to: K. Okuda     

Transmanubrial Osteomuscular Sparing Approach for Sulcus Superior Tumours

Objective: The authors report their initial experience with the transmanubrial osteomuscular sparing approach for resection of sulcus superior tumours. The feasibility of this technique is evaluated. Patients: Between February 2000 and March 2002 three patients with sulcus superior tumours were surgically treated using the transmanubrial osteomuscular sparing approach. The first two patients had a non-small cell carcinoma of the upper lobe. In the third patient a pathological diagnosis of a plasmocytoma of the first rib was made. In two cases the first thoracic root was resected.

Results: In two patients a complete R0 resection was achieved. However, an additional posterolateral thoracotomy was necessary in two patients because the costovertebral angle was difficult to address. In one patient final histologic examination found microscopically positive margins.

Conclusion: We believe that the transmanubrial osteomuscular sparing technique enables us to approach and control the subclavian vessels and brachial plexus in an oncologically responsible way and permits a radical resection of tumours invading the thoracic inlet.     

Fibrin glue and bioabsorbable felt patch for intraoperative intractable air leaks

Objective: We worked to devise a new way to prevent postoperative persistent air leaks in high-risk pulmonary surgery patients. Methods: From November 1993 to June 2002, 60 patients with difficult to control intraoperative pulmonary air leakage were treated using bioabsorbable polyglycolide felt patches soaked in fibrin glue to cover the leakage site. Results: After application, the felt patch adhered tightly to the lung surface without peeling off, enabling good leakage closure with only 2 ml of fibrin glue used. Air leakage was controlled successfully in 52 (86.7%) of the 60. Four of the 8 patients in whom this method failed to stop air leakage also developed mild pyothorax, with 2 requiring a second operation by video-assisted thoracic surgery. Leakage was eventually controlled in all patients, with no postoperative deaths relating to air leakage. Conclusions: Fibrin-glue-soaked bioabsorbable felt patches effectively seal intraoperative intractable air leaks. Felt patch use may increase the risk of postoperative infection. It should be considered for use on patients with fistulas that cannot be controlled by direct closure or otherwise intraoperatively and who may potentially develop uncontrollable air leakage postoperatively.     

Wedge resection of the portal bifurcation concomitant with left hepatectomy plus biliary reconstruction for hepatobiliary cancer

Background/Purpose: We report our experience performing wedge resection of the portal bifurcation and transverse suture closure in patients undergoing left hepatectomy and caudate lobectomy plus biliary reconstruction for hepatobiliary cancer. Methods: The procedure was performed in three patients with hilar or intrahepatic cholangiocarcinoma. After confirming that tumor invasion of the portal bifurcation was not circumferential, the portal trunk and the right posterior and right anterior portal branches were isolated and clamped. Wedge resection of the portal bifurcation was performed, taking care to secure a clear surgical margin. The edges of the portal vein were approximated, using guy-sutures in the dorsal and ventral edges and a temporary central guy-suture, and portal reconstruction was carried out using a continuous transverse suture. After unclamping, good portal flow was confirmed by color Doppler ultrasonography. Results: The procedure was completed successfully in all three patients; the average time of portal vein occlusion was 15 min. Two patients had postoperative complications: bile leakage and wound infection, but no patient developed postoperative hepatic failure or died. The three patients are alive without recurrence at 2, 11, and 22 months after the operation. Conclusions: Wedge resection of the portal bifurcation is easier and simpler than using a venous patch or performing segmental resection. Received: March 31, 2002 / Accepted: June 10, 2002 Offprint requests to: S. Kondo Presented at the 5th World Congress of the International Hepato-Pancreato-Biliary Association, April 25–29, 2002, Tokyo     

Models for Assessing the Cost-Effectiveness of the Treatment and Prevention of Osteoporosis

Received: 6 May 2002 / Accepted: 7 May 2002 Correspondence and offprint requests to: Niklas Zethraeus, Centre for Health Economics, Stockholm School of Economics, PO Box 6501, S-113 83 Stockholm, Sweden. Tel: +46 8 7369640. Fax: +46 8 302115. e-mail: henz@hhs.se     

Development of a bent-type tube stent for simultaneous drainage of bile and pancreatic juice

Background/Purpose: Endoscopic lithotomy is a useful medical procedure for treating choledocholithiasis. Although this procedure is commonly performed, complications such as pancreatitis and cholangitis are recognized as major and serious problems. The obstruction of bile and pancreatic juice flow caused by papillary edema or spasm is thought to be responsible for such complications. We have developed a new bent-type tube stent that can drain bile and pancreatic juice simultaneously. Methods: From June to November 2001, temporary implantation of the new bent-type tube stent was performed in four patients (two women, two men; mean age, 73.3 years) with choledocholithiasis, for the drainage of bile and pancreatic juice simultaneously after endoscopic lithotomy by endoscopic sphincterotomy or endoscopic balloon sphincter dilatation. Results: Immediately after the implantation of the new type of tube stent, bile and pancreatic juice flow from the respective ducts was recognized under endoscopic observation. Neither pancreatitis nor cholangitis occurred after these procedures. Conclusions: This procedure may be a helpful means to prevent pancreatitis and cholangitis after endoscopic lithotomy. Received: March 1, 2002 / Accepted: May 21, 2002 Offprint requests to: R. Abe     

Bilateral asymmetrical traumatic hip dislocation

We report a case of traumatic, simultaneous right anterior and left posterior hip dislocation without associated fractures, suffered in a high velocity traffic accident by a 35-year-old man. Closed reduction of both hips was successfully performed. The mechanism of this injury is discussed. Received: 22 February 2002, Accepted: 10 April 2002 Correspondence to: K. M. Marya     

Periodontoid pannus migration into the spinal canal with reduction of rheumatoid atlantoaxial subluxation: a case report

 We report a patient with rheumatoid arthritis in whom periodontoid pannus migrated into the spinal canal with reduction of atlantoaxial subluxation. In this case, magnetic resonance imaging in the extension position was valuable for determining the therapeutic strategy. Received: February 5, 2002 / Accepted: June 18, 2002 Offprint requests to: H. Ishihara     

How to do a safe pancreatic anastomosis

Background/Purpose: Leakage of pancreaticojejunostomies has been associated with morbidity and mortality after pancreatic head resection. Different techniques have been described to perform a safe anastomosis to the left pancreatic remnant. Methods: The pancreaticojejunostomy is preferably performed as an end-to-side anastomosis; drainage of the pancreatic duct by catheters or stents is not performed at our institution. Results: Experience in more than 331 patients who underwent pancreaticojejunostomy indicates that a two-layer, single-stitch technique, with absorbable monofilament sutures and duct-to-mucosa adaptation, is a reliable method, with a pancreatic fistula rate of 2%. Conclusions: The results obtained with the described technique of pancreaticojejunostomy indicate that the pancreatic anastomosis is very safe when performed by experienced hands and does not necessarily contribute to morbidity and mortality after pancreatic head resection. The prevalence of pancreatic fistulae and intraabdominal abscesses may further decrease, and the prevalence of nonpancreatic complications may have a more important impact on the outcome in the future. Received: March 20, 2002 / Accepted: April 15, 2002 Offprint requests to: M.W. Büchler     

Preoperative Physical Examination for Primary Vascular Access — Reliability in Determining Vessel Quality

Background and aims: The purpose of this prospective clinical study was to evaluate the reliability and adequacy of preoperative physical examination in determining the quality of vessels prior to primary vascular access procedure by performing peroperative completion fistulography.

Material and methods: 26 consecutive patients who were scheduled for primary vascular access surgery, between July 2001 and June 2002, were included. Findings between the preoperative physical examination and peroperative completion fistulography were compared.

Results: Of the 26 patients that were initially enrolled in the study, 4 patients were excluded because physical examination showed poor superficial arm veins and 2 patients had not undergone access procedure by the end of the study. The remaining twenty patients constituted the actual study group. The arteriovenous fistula could be performed at the chosen level and way in all 20 patients. The findings between preoperative physical examination and peroperative fis-tulography were compatible and the specificity of physical examination to detect patent inflow and outflow vessels was 100%. Due to the fact that 4 patients in whom a poor vein was suspected were excluded, the sensitivity could not be assessed.

Conclusions: Preoperative physical examination seems to be reliable and adequate method in determining vessel quality prior primary vascular access surgery. According to our study, its specificity is high in determining patent inflow and outflow vessels. However, because of exclusion of patients with suspected problem, sensitivity cannot be determined.     

Liver resection for hepatic metastases: 15 years of experience

Background/Purpose: Liver metastases, especially those from primary colorectal cancers, are treatable and potentially curable. Imaging techniques such as computed tomography, magnetic resonance, and ultrasonography have advanced in recent years and led to increased sensitivity and specificity in the diagnosis of liver metastases. Liver surgery also has been revolutionized in the past two decades. Dissection along nonanatomical lines has permitted the resection of multiple lesions that previously might have been considered unresectable. Methods: From 1986 to 2000, 181 patients underwent liver resection for hepatic metastasis from colorectal cancer. Of these, 56 patients underwent systematic anatomical major hepatic resection and 125 underwent nonanatomical limited resection. Results: Operative morbidity and mortality rates were higher in patients in whom anatomical procedures were performed. The overall 5-year survival rate of the 181 patients was 39.8%. Conclusions: An aggressive surgical procedure in patients with hepatic colorectal metastases is safe, and may prolong overall survival, and therefore should be considered in all patients with metastases confined to the liver. Received: April 14, 2002 / Accepted: May 12, 2002 Offprint requests to: G. Belli Via Cimarosa 2/a, 80127 — Naples, Italy Accepted at fifth World Congress of the International Hepato-Pancreato-Biliary Association (IHPBA)     

Rectal malignant melanoma diagnosed by N-isopropyl- p-123I-iodoamphetamine single photon emission computed tomography and 5-S-cysteinyl dopa: report of a case

Malignant melanoma in the anorectal region is a rare disease associated with a very poor prognosis. Taking a biopsy of malignant melanoma is generally contraindicated because of the high risk of inducing metastasis. Although clinical examination and imaging findings are important for the preoperative diagnosis, conventional imaging techniques sometimes fail to provide information from which an accurate diagnosis can be made. We recently treated an 84-year-old woman with rectal malignant melanoma, in whom magnetic resonance imaging showed atypical findings. On the other hand, N-isopropyl-p-¹²³I-iodoamphetamine single photon emission computed tomography and 5-S-cysteinyl dopa in blood serum, as a tumor marker of malignant melanoma, proved very effective for establishing the preoperative diagnosis. Despite radical abdominoperineal resection, the patient died of multiple liver and lung metastases about 5 months after surgery. Received: April 8, 2002 / Accepted: November 19, 2002 RID="*" ID="*" Reprint requests to: S. Sato     

Endoscopic treatment of postoperative colorectal anastomotic strictures

Background: The postoperative development of benign colorectal anastomotic stricture remains a frequent and unsolved problem. Methods: From 1996 until 2002, we analyzed 94 consecutive patients with postoperative colorectal anastomotic stenosis who were treated endoscopically. Results: Sixty-eight patients were initially resected for malignant disease, and 26 patients for benign conditions. Most frequently, hydrostatic balloon dilatation was performed; in selected cases, it was combined with a laser or argon plasma coagulation (APC) incision, or a laser incision only. Dilatation was successful in 59% of patients resected for cancer and 88% resected for a benign condition. Complications developed in 17 patients (benign restenosis, perforation, abscess); they were significantly more frequent after initial cancer resection than after resection for a benign condition (p < 0.05). Conclusion: High success and low complication rates make endoscopic dilatation the treatment of choice to avoid high-risk reoperations in patients with benign anastomotic stricture. The presence of stapler anastomosis, postoperative leakage, and/or radiotherapy does not significantly impede successful endoscopic dilatation. Presented at the combined meeting of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the 8th World Congress of Endoscopic Surgery, New York, NY, USA, 13–16 March 2002     

Detection of serum MMPs in tumor-bearing hamsters

Background/Purpose: Matrix metalloproteinases (MMPs) have been implicated as playing an important role in cancer invasion and metastasis. MMPs have been identified in various malignancies, including pancreatic duct adenocarcinomas. Methods: We investigated the circulating level of MMP-2 and MMP-9 in sera from Syrian golden hamsters into which hamster pancreatic duct adenocarcinoma tissues had been transplanted subcutaneously (HPDt hamsters). Northern blot analysis and gelatin zymographic analysis were performed to detect the expression of MMPs and that of tissue inhibitors of metalloproteinases (TIMPs) in HPDt hamsters. Results: Northern analysis revealed overexpression of MMP-2, MMP-9, and TIMP-2 mRNAs in subcutaneous tumors of HPDt hamsters as compared with normal pancreatic tissue. Sera from HPDt hamsters possessed significantly higher levels of serum MMP-2 and MMP-9 than control sera, as determined by gelatin zymographic analysis, and there was a significant correlation between tumor growth and serum MMP levels. Conclusions: These results indicate that overexpression of MMP mRNAs is involved in the progression of pancreatic duct adenocarcinomas, and that MMP protein expression in hamster sera is associated with the presence of pancreatic duct adenocarcinoma cells. The findings also suggest that serum MMPs could be useful markers for monitoring patients with pancreatic duct adenocarcinomas. Received: February 6, 2002 / Accepted: June 10, 2002 Offprint requests to: K. Iki     

Complete paralysis of the quadriceps muscle caused by traumatic iliacus hematoma: a case report

 A 15-year-old girl who developed traumatic iliacus hematoma and complete paralysis of the quadriceps muscle is reported. The current case and literature review revealed that incomplete quadriceps paralysis associated with traumatic iliacus hematoma is likely to progress to complete paralysis in days or weeks as a result of increased intracompartmental pressure. However, surgical decompression of the femoral nerve could produce good results even in patients who have complete quadriceps paralysis preoperatively. Received: April 9, 2002 / Accepted: June 28, 2002 Offprint requests to: K. Tamai     

Impact of a Clinical Pathway and Standardization of Treatment for Acute Appendicitis

Purpose: Acute appendicitis is one of the most common surgical diseases. Simple and precise guidelines for treating acute appendicitis are necessary for improving the treatment outcome of this disease. The purpose of this study was to determine the impact of a clinical pathway and standardization of treatment for acute appendicitis at our hospital. Methods: The clinical pathway and standardization of treatment for acute appendicitis were introduced to our hospital in January 2000. We compared the length of hospitalization, postoperative stay, hospital costs, and operation time during the years before and the years after their introduction. Results: There was no significant difference in the clinical characteristics of the 73 patients in the control group and the 112 patients in the pathway group. There were 6 (8.2%) and 24 (21.4%) cases of perforated appendicitis in the respective groups. The mean length of hospitalization (P < 0.001), postoperative stay (P < 0.001), and hospital costs (P < 0.01) were significantly less in the patients in the pathway group who underwent surgery. Conclusion: Our clinical pathway and standardization of treatment for acute appendicitis proved effective for treating patients with acute appendicitis and minimizing costs without compromising patient care. Received: February 19, 2002 / Accepted: November 19, 2002 Reprint requests to: K. Takegami (address 2)     

Nationwide trends in the prescription of beta-blockers and angiotensin-converting enzyme inhibitors after myocardial infarction in Denmark, 1995–2002

Objectives To study the use of beta-blockers and angiotensin-converting enzyme (ACE) inhibitors after acute myocardial infarction (AMI) in Denmark from 1995 to 2002.

Design Information about patients with first AMI aged ≥30 years and the dispensing of beta-blockers and ACE inhibitors from pharmacies within 30 d from discharge was obtained from the National Patient Registry and the Danish Registry of Medicinal Product Statistics.

Results Beta-blocker use increased from 38.1% of patients in 1995 to 67.9% in 2002 (OR=3.85, CI: 3.58–4.13). Women, elderly patients and patients taking loop-diuretics and antidiabetic drugs received beta-blockers less frequently, but patients taking loop-diuretics or antidiabetic drugs had the greatest increase. ACE inhibitor use increased from 24.5 to 35.5% (OR=1.86, CI: 1.72–2.01). Women, patients aged <60 years or ≥80 years and patients not taking loop-diuretics received ACE inhibitors less frequently, but patients not taking loop-diuretics had the greatest increase.

Conclusions Beta-blocker use increased markedly post-AMI from 1995 to 2002, whereas ACE inhibitor use increased modestly. The results suggested undertreatment of women, elderly patients and people with diabetes.     

A nonsurgical technique to create an esophagostomy for difficult cases of percutaneous endoscopic gastrostomy

Background: We developed a minimally invasive technique of esophagostomy called percutaneous transesophageal gastrotubing (PTEG) using a rupture-free balloon (RFB) for enteral nutrition and drainage as well as percutaneous endoscopic gastrostomy (PEG). PTEG using RFB allows surgeons to create a nonsurgical esophagostomy even in difficult cases of PEG (i.e., total gastrectomized patients and massive ascites). Methods: To create the PTEG, a RFB is inserted into the esophagus through the nose and inflated. The RFB is punctured with a needle at the left neck under ultrasonographic vision. A guidewire is inserted through the needle, followed by dilatation of the punctured site using a dilator with sheath. Finally, the tube is inserted into the gastrointestinal tract and the sheath is peeled off. Results: From January 1998 to June 2002, we treated 115 patients using PTEG with a RFB and there were no major complications. Therapeutic results are as good as those for PEG and it took approximately 15 min to perform. Conclusions: PTEG with RFB is as safe as PEG and is simple and less invasive. It can be used in some cases for which PEG is contraindicated. Paper presented at the annual meeting of the eighth World Congress of Endoscopic Surgery (WCES) hosted by SAGES, New York, NY, USA, March 2002     

Analysis of linear growth in survivors of childhood acute lymphoblastic leukemia

 Therapy for childhood acute lymphoblastic leukemia (ALL) is entering a new era in terms of quality-of-life. In the current study, 21 patients with childhood-onset ALL were assessed for linear growth, bone mineral density (BMD), and endocrinological status, focusing especially on longitudinal analysis of the growth of each patient. Linear growth was uniformly attenuated during therapy in all patients. In contrast, after the cessation of therapy, the growth of each patient varied widely from attenuated to dramatic catch-up growth. In pubertal survivors who had received chemotherapy and cranial irradiation during prepuberty, the degree of growth after the cessation of therapy was negatively correlated with changes in height Z scores during therapy (r = −0.76, P = 0.004). One of the factors involved in catch-up growth, urinary N-telopeptide/creatinine (U-NTx/Cr), was significantly higher in patients whose Z scores decreased after cessation of therapy (P = 0.01), despite normal pubertal development and normal endocrinological assessments. The present study revealed individual differences in linear growth after the cessation of therapy and suggests the importance of catch-up growth during puberty. Received: August 29, 2002 / Accepted: November 11, 2002 Acknowledgments. This study was supported by grants from the Ministry of Health and Welfare and the Ministry of Education of Japan. Offprint requests to: H. Tanaka     

Minilaparotomy Approach to Colon Cancer

Purpose. Many studies have proved the feasibility and safety of a laparoscopic colectomy in comparison to a conventional laparotomy. However, a laparoscopic colectomy requires a minilaparotomy incision to perform the operative procedure. We have introduced a minilaparotomy technique which can perform all the operative procedures through incisions measuring from 3 to 7 cm in length. Methods. A retrospective comparison of the outcome after a potentially curative resection of colon cancers via minilaparotomy (July 2000 to May 2002) and by conventional laparotomy (May 1997 to June 2000) is reported. Results. The patient cohort consisted of 27 minilaparotomy cases and 24 conventional laparotomy cases. The patients' characteristics were similar in the two groups. The oncological clearance, in terms of the length of resected specimens, was similar in the two groups, whereas the number of lymph nodes removed was significantly higher in the minilaparotomy group. In addition, the mean operation time, blood loss, length of the laparotomy incision, postoperative time to walking, starting oral intake, and postoperative hospitalization were significantly smaller in the minilaparotomy group. Conclusion. Our minilaparotomy approach maintained the same curative resection for colon cancers as a conventional laparotomy, but it was less invasive and allowed for an earlier recovery and hospital discharge than conventional laparotomy. The minilaparotomy approach is thus considered to be an attractive alternative to conventional colon surgery. Received: March 28, 2002 / Accepted: November 19, 2002 RID="*" ID="*" Reprint requests to: K. Takegami (address 2)