Risk factors for major morbidity after liver resection for hepatocellular carcinoma

Background:

Bile leakage, and organ and/or space surgical‐site infection (SSI) are common causes of major morbidity after partial hepatectomy for hepatocellular carcinoma (HCC). The purpose of this study was to analyse risk factors for major morbidity and to explore strategies for its reduction after partial hepatectomy for HCC.

Methods:

Risk factors for bile leakage and organ/space SSI were analysed in patients who underwent partial hepatectomy for HCC between 2001 and 2010. The causes, management and outcomes of intractable bile leakage requiring endoscopic therapy or percutaneous transhepatic biliary drainage were analysed. In addition, causative bacteria, outcomes and characteristics of organ/space SSI were investigated. Risk factors were identified using multivariable analysis.

Results:

Some 359 patients were included in the analysis. The prevalence of bile leakage and organ/space SSI was 12·8 and 8·6 per cent respectively. Repeat hepatectomy and an operating time of at least 300 min were identified as independent risk factors for bile leakage. The main causes of intractable bile leakage were latent strictures of the biliary system caused by previous treatments for HCC and intraoperative injury of the hepatic duct during repeat hepatectomy. Independent risk factors for organ/space SSI were repeat hepatectomy and bile leakage. Methicillin‐resistant Staphylococcus aureus was detected more frequently in organ/space SSI after repeat hepatectomy than after initial partial hepatectomy.

Conclusion:

Repeat hepatectomy and prolonged surgery were identified as risk factors for bile leakage after liver resection for HCC. Bile leakage and repeat hepatectomy increased the risk of organ/space SSI. Copyright © 2012 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.     

Periurethral injection of autologous adipose‐derived regenerative cells for the treatment of male stress urinary incontinence: Report of three initial cases

Objectives: To report a novel cell therapy using autologous adipose tissue‐derived regenerative cells for male stress urinary incontinence caused by urethral sphincteric deficiency, and the outcomes in the initial cases undergoing periurethral injection of adipose tissue‐derived regenerative cells. Methods: Three patients with moderate stress incontinence after radical prostatectomy and holmium laser enucleation of the prostate were enrolled. Adipose tissue‐derived regenerative cells were isolated from the abdominal adipose tissue by using the Celution system. Subsequently, the isolated adipose tissue‐derived regenerative cells, and a mixture of adipose tissue‐derived regenerative cells and adipose tissue were transurethrally injected into the rhabdosphincter and submucosal space of the urethra, respectively. Short‐term outcomes during a 6‐month follow up were assessed by a 24‐h pad test, a validated patient questionnaire, urethral pressure profile, transrectal ultrasonography and magnetic resonance imaging. Results: Urinary incontinence progressively improved after 2 weeks of injection up to 6 months in terms of decreased leakage volume, decreased frequency and amount of incontinence, and improved quality of life. Both maximum urethral closing pressure and functional profile length increased. Magnetic resonance imaging suggested a sustained presence of the injected adipose tissue. Enhanced ultrasonography showed a progressive increase in the blood flow to the injected area. No significant adverse events were observed peri‐ and postoperatively. Conclusion: These preliminary findings suggest that periurethral injection of the autologous adipose tissue‐derived regenerative cells is a safe and feasible treatment modality for male stress urinary incontinence.     

Safety and indication of open heart surgery without blood transfusion for congenital cardiac defects in infants]

Between January 1994 and June 1997, 16 cases of ventricular septal defect (VSD) and endocardial cushion defect (ECD) with pulmonary hypertension (PH), each weighing from 5 to 9 kg, underwent definitive surgery at Matsudo Municipal Hospital. We classified them into 2 groups; Group N: 8 cases without blood transfusion, Group H: 8 cases with blood transfusion. Cardiopulmonary bypass (CPB) system was a closed circuit and priming volume was 370 to 500 ml. There was no difference between the 2 groups in operative age, body weight, preoperative state, operation time, CPB time, aortic cross clamp time, bleeding and postoperative state. In Group N, CPB blood was returned to the patient as soon as possible after CPB was weaned, and postoperative hemodynamics were stable in both groups. In Group N, hematocrit (Ht) values were consistently lower than in Group H, from initiation of CPB to leaving the hospital. To accomplish safe CPB, we measured systemic venous oxygen saturation (SvO2). In 6 cases of Group N, SvO2 during rewarming was 48.1 +/- 16.0% and Ht value was 13.2 +/- 1.5%. It is thought that the safe CPB could be conducted in Group N. In addition, in Group N, respiratory index showed better values than in Group H during the postoperative period. It is thought that CPB without blood transfusion may be favorable to prevent lung injury after CPB. Retrospectively, it is thought that, to accomplish safe CPB without blood transfusion, preoperative Ht values of over 30% are desirable in patients weighing 6 kg and those of over 35% are desirable in patients weighing 5 kg.     

Greater thickness of the aortic wall on postmortem computed tomography compared with antemortem computed tomography: the first longitudinal study

Objectives

To evaluate postmortem changes of the aorta on postmortem computed tomography (CT) in comparison with those on antemortem CT obtained in the same patients.

Materials and Methods

We studied 57 consecutive patients who had undergone antemortem CT, postmortem CT, and pathological autopsy in our tertiary care hospital between April 2009 and December 2010. Postmortem CT was performed within 20 h after death, followed by pathological autopsy. Pathological autopsy confirmed the absence of cardiovascular disease such as aortic aneurysm, aortic dissection, or Marfan syndrome in all patients. Aortic wall thickness and aortic cross-sectional areas were measured on both antemortem CT and postmortem CT. Difference in aortic wall thickness between antemortem CT with and without contrast medium, and between antemortem CT and postmortem CT, and in cross-sectional area of the aortic wall between antemortem CT and postmortem CT was evaluated statistically.

Results

No significant difference in aortic wall thickness was observed on antemortem CT in comparison of contrasted and non-contrasted images. The aortic wall was significantly thicker on postmortem CT than on antemortem CT (p?Conclusion This is the first longitudinal study to confirm greater thickness of the aortic wall on postmortem images compared with antemortem images in the same patients and to show no change in cross-sectional area of the aortic wall between before and after death.     

Open heart surgery without blood transfusion for cyanotic congenital cardiac defects

Between November 1994 and January 1997, 42 cases of cyanotic congenital cardiac defects underwent definitive surgery at Matsudo Municipal Hospital. We evaluated 30 cases, each weighing from 7 to 20 kg. The procedures were performed at the age of 9 months to 6 years (mean age—2.4 years). The body weights were 7.7 to 20 kg (mean weight—11.4 kg). The preoperative diagnoses were Tetralogy of Fallot (TOF) in 19 cases, Fontan candidates in 6 and the others in 5. We classified them into 3 groups; Group Abstract—15 cases were completed with non-blood transfusion, Group B—8 cases used only plasma protein fraction and Group C—7 cases used blood transfusion. Cardiopulmonary bypass (CPB) system is a semi-closed circuit and priming volume is 400 to 600 ml. There is no difference among the 3 groups in operative age, body weight, opeartion time, CPB time, aortic cross clamp time, bleeding and postoperative state. The same results were obtained in minimum base excess and urine output during CPB and the changes of hematocrit and total protein. In Groups A and B, CPB blood was retruned to the patient as soon as possible after CPB was weaned, but in Group C, blood transfusion was performed without the return of CPB blood. In all groups, hemodynamics were stable. Retrospectively, it is thought that blood transfusion was not necessary in Group C and the use of the plamsa protein fraction was not needed in Group B. In conclusion, the open heart surgery can be performed safely without blood transfusion for cyanotic congenital cardiac defects.     

Expression of mouse HtrA1 serine protease in normal bone and cartilage and its upregulation in joint cartilage damaged by experimental arthritis

Levels of HtrA1 protein in cartilage have been reported to elevate in joints of human osteoarthritis patients. To understand roles of HtrA1 in normal osteogenesis as well as in pathogenesis of arthritis, we examine HtrA1 expression pattern during bone and cartilage development and in articular cartilage affected by experimental arthritis. HtrA1 is not expressed in mesenchymal or cartilage condensations before initiation of ossification. When ossification begins in the condensations, the expression of HtrA1 starts in chondrocytes undergoing hypertrophic differentiation near the ossification center. Hypertrophic chondrocytes found in adult articular cartilage and epiphyseal growth plates also express HtrA1. When arthritis is induced by injection of anti-collagen antibodies and lipopolysaccharide, resting chondrocytes proceed to terminal hypertrophic differentiation and start expressing HtrA1. These data suggest that hypertrophic change induces HtrA1 expression in chondrocytes both in normal and pathological conditions. HtrA1 has been reported to inhibit TGF-beta signaling. We show that HtrA1 digests major components of cartilage, such as aggrecan, decorin, fibromodulin, and soluble type II collagen. HtrA1 may, therefore, promote degeneration of cartilage by inducing terminal hypertrophic chondrocyte differentiation and by digesting cartilage matrix though its TGF-beta inhibitory activity and protease activity, respectively. In bone, active cuboidal osteoblasts barely express HtrA1, but osteoblasts which flatten and adhere to the bone matrix and osteocytes embedded in bone are strongly positive for HtrA1 production. The bone matrix shows a high level of HtrA1 protein deposition akin to that of TGF-beta, suggesting a close functional interaction between TGF-beta and HtrA1.     

CD133 Expression at the Metastatic Site Predicts Patients’ Outcome in Colorectal Cancer with Synchronous Liver Metastasis

Background

CD133 is a transmembrane protein that is proposed to be a stem cell marker of colorectal cancer (CRC); however, the correlation between CD133 expression and survival of CRC patients with liver metastasis has not been fully examined.

Methods

CD133 expression was evaluated immunohistochemically, both in primary tumors and synchronous liver metastases of 88 consecutive CRC patients, as well as recurrent lesions in the remnant liver of 27 of these 88 patients. The relationship between CD133 expression and clinicopathological characteristics, recurrence-free survival, and overall survival (OS) was analyzed.

Results

CD133 expression in liver metastases (mCD133) was detected in 50 of 88 patients (56.8 %), and had significant correlation with CD133 expression in primary lesions (pCD133) (p < 0.001). CD133 expression in liver recurrent lesions (recCD133) also had a significant correlation with mCD133 (p < 0.001). mCD133+ patients had significantly longer disease-free survival (p = 0.043) and OS (p = 0.014) than mCD133? patients. In addition, mCD133+ patients had a significantly lower rate of extrahepatic recurrence (p < 0.001).

Conclusions

Patients without CD133 expression in liver metastasis had significantly shorter survival, perhaps because mCD133? patients had a significantly higher rate of extrahepatic recurrence.

     

Surgical treatment of lumbar ossification of the posterior longitudinal ligament. Report of two cases and description of surgical technique

The authors report two cases of patients with lumbar ossification of the posterior longitudinal ligament (OPLL). One patient underwent surgery via the single posterior approach, and the other patient underwent combined anterior-posterior surgery. The authors consider the anterior approach for excision of the ossified lesion to be the most reasonable for treatment of lumbar OPLL. It is extremely important, however, to select the surgical procedure according to the individual patient's condition.