Resection for multiple metastatic liver tumors after portal embolization

BACKGROUND: Five patients with bilateral multiple liver metastases (3 to 12 lesions) from colorectal cancer who underwent extensive liver resection after portal embolization are described. METHODS: Portal embolization of the right portal branch was performed 9 days to 8 months before hepatic resection. The location and number of metastases were determined by intraoperative ultrasonography at the time of liver resection to accomplish complete resection of the tumors. Extended right lobectomy was carried out in four patients, two of whom underwent additional wedge resection of nodules located in the left lateral segment. The other patient underwent right lobectomy associated with local resection of the tumor in the left lobe. RESULTS: The postoperative course in the five patients was uneventful, with no serious complication or liver dysfunction. Although one patient died of recurrence 28 months after liver resection, the remaining four patients were alive and free of cancer between 36 and 74 months after hepatectomy. CONCLUSIONS: The presence of bilateral multiple (four or more) metastatic liver lesions from colorectal cancer is not considered a contraindication for hepatic resection if thorough examination of the liver is performed with intraoperative ultrasonography and the surgical risk is minimal. Portal embolization appears effective for increasing the safety of hepatectomy for patients with small metastases who require major right-sided resection combined with wedge resection of the left lobe.     

Altered endothelin homeostasis in patients undergoing liver transplantation

The liver is a major site of synthesis, clearance, and actions of the powerful vasoactive peptide endothelin-1 (ET-1). We investigated the role of the liver in ET-1 homeostasis by comparing circulating and hepatic ET-1 levels and hepatic ET receptors in patients undergoing orthotopic liver transplantation (OLTx) for end-stage liver disease (ESLD) with those in patients undergoing liver resection for focal lesions with otherwise normal hepatic synthetic function. Central venous and radial arterial blood was drawn immediately after induction of anesthesia (point I), 10 minutes before beginning of resection or the anhepatic stage (point II), and 30 minutes after completion of resection or reperfusion of the grafted liver (point III). Portal and hepatic venous blood was drawn at points II and III. Plasma ET-1 levels were higher in ESLD patients than in resection patients. Plasma ET-1 levels rose both during resection and transplantation; the increase in ET-1 was more pronounced during transplantation. In ESLD patients, hepatic venous ET-1 was higher than portal venous ET-1, suggesting reduced clearance and/or enhanced synthesis of the peptide in the cirrhotic liver. Conversely, hepatic venous ET-1 was lower than portal venous ET-1 in resection patients at all time points and at point III in the ESLD patients. Hepatic concentration of ET-1 was greater and the capacity of the liver to catabolize ET-1 was reduced in ESLD patients as compared to the resection patients. Further, hepatic ET receptor density was higher in ESLD than in resection patients. These results suggest that the cirrhotic liver may contribute to elevated plasma ET-1 in ESLD. Considering its potent hemodynamic and metabolic effects in the liver, increased hepatic ET-1 and ET receptors and plasma ET-1 could play a role in the pathophysiology of liver disease and perioperative complications of OLTx.     

Rat maf related genes: specific expression in chondrocytes, lens and spinal cord

Excess parenchymal loss associated with hepatectomy is the leading risk factor/for liver failure especially in patients with impaired hepatic function. Selective portal embolization (PE) before hepatectomy is aimed to induce an atrophy of the embolized lobe to be resected, with a compensatory hypertrophy of the/counterlobe to be preserved. We performed PE followed by hepatectomy in 58 patients with hepatocellular carcinoma (HCC, n. = 44) or metastatic liver tumour (MLT, n. = 14). All the patients well tolerated PE, and hepatic functional data returned to the baseline levels within a week. The left lobe volume increased by about 10% after the right PE. Hepatectomy procedures undertaken comprised right or extended right lobectomy (n. = 39), central bisegmentectomy (n. = 3), extended segmentectomy (n. = 12), and limited resection (n. = 4). The 25 of HCC patients underwent right-sided lobectomy despite a presence of hepatic functional impairment, and the 3 of MLT patients under went right lobectomy with additional resection of the left lobe. As a whole, the operative morbidity and mortality rates were 15.5% and 1.7%, respectively (one patient died of liver failure). The 5-year over all survival rates were 46.8% in HCC patients and 38.0% in MLT patients, respectively. Preoperative PE therefore can be an ancillary procedure for patients, despite with hepatic dysfunction or with bilobar tumours, who may need extensive hepatectomy.     

Indications for major hepatectomy in cirrhotic liver

In an investigation of the indications for major hepatic resection of the cirrhotic liver, the records of 152 consecutive patients who had undergone a right hepatic resection between April 1985 and January 1991 were reviewed. A comparison of right hepatic lobectomy and right partial hepatectomy of the liver with no cirrhotic changes, revealed that postoperative values of serum glutamic pyruvic transaminase were significantly higher after right partial hepatectomy than after right lobectomy, despite the fact that there were no significant differences with respect to preoperative laboratory data, and there was a greater blood loss and total weight of the resected liver in patients receiving a right lobectomy as compared with those undergoing partial hepatectomy. These results suggest that in order to enable a more favorable recovery from hepatic resection, it is essential to avoid both mechanical damage and ischemic injury to the residual liver during hepatic surgery. A total of 77 patients underwent a partial hepatectomy of a cirrhotic liver, and among these patients, 16 patients had values of the indocyanine green test of less than 20%, as well as a portal pressure of less than 200 mm saline. Compared with these 16 cirrhotic patients and those patients who underwent right lobectomy, there were no significant differences with regard to the pre-operative laboratory data and portal pressure. These results therefore suggest that major hepatic lobectomy could be performed on selected patients with cirrhotic livers.     

Simple method of hyperthermo-chemo-hypoxic isolated liver perfusion for hepatic metastases

As a regional therapy for hepatic malignancy, we developed a simple method of isolated liver perfusion (hyperthermo-chemo-hypoxic). In the present study, the influence of this method on the hepatic tissue and other organs was experimentally evaluated and applied it to seven patients. Experimentally, all dogs survived without hepatic insufficiency and systemic toxicity. Clinically, one patient died on postoperative day 14 of hepatic failure. The reason was that liver temperature reached 43 degrees C, which seemed to be the maximum limit for thermal toxic effect to the human liver. The other six patients well tolerated the perfusion with mild increases of serum aminotransferase and total bilirubin levels and decreases of hepaprastin levels. Serum aminotransferase and total bilirubin and hepaprastin levels returned to normal levels by postoperative day 14. There were no significant differences between the isolated liver perfusion group (n = 7) and hepatectomy-only group (n = 27). Six patients were disease-free during the observation period after the perfusion. This system is a simple, useful method for treating patients with metastatic cancer limited to the liver.     

Liver transplantation in acute liver failure

Acute hepatic failure is characterized by jaundice and hepatic encephalopathy within eight weeks after the onset of disease. Although acute hepatic failure is a rare occurrence, its rapid progression and high mortality (50 to 90%, depending on the etiology of disease) necessitate immediate intervention. In the absence of causal therapy, orthotopic liver transplantation is currently the only definitive and effective means of treating acute hepatic failure in Europe, acute hepatic failure accounts for 11% of all liver transplantations. At the University department of transplantation surgery in Vienna a total of 27 patients with acute hepatic failure underwent 31 liver transplantations in the last 10 years (1.1.1987 to 31.12.1996). Twenty (74%) of the 27 patients survived the acute event and were discharged from hospital in good general condition after a median postoperative stay of 25 days (range 14-81 days). Seven patients (26%) died between the first and 34th postoperative day (median 26 days) in the intensive care unit, although all potential modern options of intensive care and surgery were used. The causes of death were irreversible cerebral edema (n = 3), multiple organ failure due to bacterial sepsis (n = 3) and uncontrollable haemolysis (n = 1). With a 3-year graft survival rate of 70% the 3-year patient survival rate was 74%. A retrospective analysis of our patients revealed that the postoperative graft function and the incidence of re-transplantation were significant prognostic factors (p < 0.05) for survival following orthotopic liver transplantation for acute hepatic failure. In the absence of further prognostically relevant preoperative indices and in consideration of the potentially fulminant progression of disease, we strongly recommend that any patient, in whom acute hepatic failure is suspected, is immediately transferred to a specialized center with experience both in the conservative treatment of acute hepatic failure and emergency liver transplantation.     

Hepatic resection for colorectal liver metastases

The lack of other effective treatment for colorectal liver metastases makes hepatic resection a primary treatment consideration. Between January 1980 and December 1990, 26 selected patients with liver colorectal metastases who underwent hepatic resection were reviewed. The age, sex, site of primary lesion, histological grade, lymph node involvement, location, size, and number of hepatic metastases, type of hepatic resection, and preoperative CEA blood levels were documented. Complete removal with histologically negative resection margins were accomplished in 24 patients. The extent of resection performed was hepatic lobectomy in 12 patients. Segmentectomy in eight patients, and wedge resection in four patients. The 5-year survival rate was 30.5 per cent. Patients with metachronous metastases showed a better survival rate than those with synchronous lesions--46.6% versus 13.6% respectively (P = 0.08). None of the other factors studied showed a significant effect on survival. All patients were followed from the time of hepatic resection to the time of this study or death. During a median follow-up of 30.9 months, 20 patients developed recurrence of their disease (60 per cent in the liver). There was no perioperative mortality. Morbidity arose in 66.6 per cent of patients, with a majority of the complications being minor. We conclude that hepatic resection can be performed safely enough to be recommended in selected patients.     

Angiosarcoma of the liver in children

The clinico-pathological features of four cases of pediatric hepatic angiosarcomas are described. One case was initially diagnosed in infancy and underwent resection of a left-sided benign hemangioendothelioma of the liver. Further resection of a lesion in the right liver was followed by malignant transformation. Primary hepatic resection of the tumor was not possible in three other cases, and all received courses of chemotherapy without significant tumor shrinkage. One child underwent liver transplantation but died 4 months later of immunosuppression complications. The remaining three children died of disseminated malignancy. Histological verification of malignancy was difficult in three cases in which there was discrepancy between the rapid growth of the liver tumor and the microscopic features of benign hemangioendothelioma.     

Treatment of cirrhotic rats with epidermal growth factor and insulin accelerates liver DNA synthesis after partial hepatectomy

Prevention of postoperative hepatic failure is important after hepatic resection. In patients with cirrhosis, impaired liver function and regenerative capacity after major hepatic resection are associated with increased morbidity and mortality. In this study, a combination of epidermal growth factor (EGF) and insulin were used as hepatotrophic factors in an attempt to stimulate DNA synthesis after 70% hepatectomy (HTX). Regenerative capacity was evaluated in normal and cirrhotic rat liver by measuring DNA synthesis in vivo. Micronodular liver cirrhosis was established by the simultaneous oral administration of CCl4 and phenobarbital. Epidermal growth factor plus insulin was injected subcutaneously immediately after and 12 h after HTX or sham operation was performed. Rats were killed 24 h after the operation and liver regeneration was estimated by [3H]-thymidine incorporation into DNA as well as an autoradiographic nuclear labelling index. Hepatectomy increased [3H]-thymidine incorporation significantly in both normal and cirrhotic rats. In cirrhotic rats, [3H]-thymidine incorporation after HTX was significantly lower than in normal rats and administration of a combination of EGF and insulin after HTX enhanced [3H]-thymidine incorporation. In conclusion, DNA synthesis 24 h after HTX is decreased in cirrhotic rats compared with normal rats and EGF supplementation with insulin accelerates DNA synthesis in hepatectomized cirrhotic rats. The data suggest that administration of combinations of exogenous hepatotrophic factors may play a useful role in the treatment of cirrhotic patients undergoing major hepatic resection.     

Partial hepatic resection for ischemic graft damage after liver transplantation: a graft-saving option?

BACKGROUND: Intrahepatic biliary strictures or parenchymal infarcts may occur after liver transplantation as a complication of ischemic damage to the graft. In some selected cases the lesions appear to be confined to a part of the liver. We report our experience with partial graft resection in this setting. METHODS: From January 1984 to December 1991, 286 liver transplantations were performed in 257 recipients. Seven patients, three children and four adults, underwent partial hepatectomy 3 to 218 weeks after liver transplantation of a full-size graft. The clinical presentation included septic parenchymal infarcts (n = 4) and nonanastomotic biliary strictures (n = 3) complicating (n = 5) artery thrombosis or not (n = 2). There were four left hepatectomies, two left lobectomies, and one right hepatectomy. In four instances partial hepatectomy was performed after failed attempt at biliary reconstruction (n = 2) or arterial revascularization (n = 2). Partial graft resection was performed extrafascially without Pringle's maneuver and mobilization of the remnant liver to preserve its vascularization. RESULTS: No surgical complications occurred, and none of the patients experienced acute hepatic failure during the postoperative period. All patients were discharged home 10 to 96 days (median, 23 days) after liver resection. Two patients had recurrent ischemic cholangitis. One patient underwent successful regrafting for recurrent Budd-Chiari syndrome; one patient died of tumor recurrence. Six patients were alive with a follow-up ranging from 12 to 45 months. CONCLUSIONS: These results suggest that partial graft resection is a safe and graft-saving option after liver transplantation in selected patients with localized ischemic damage of the graft.     

Study of the changes of serum hyaluronic acid during porcine liver transplantation: influence of warm ischemia

Twelve porcine liver transplantations were performed to investigate whether serum hyaluronic acid (HA) serves as a marker of warm ischemic injury. Group 1 was a control without warm ischemia (n = 7), and pigs in Group 2 were sacrificed by intracardiac KCl injection 60 min before harvesting (n = 5). All pigs survived more than 4 days in Group 1. In Group 2, all died within 2 days due to graft failure. Arterial and hepatic venous glutamic-oxaloacetic transaminase (GOT) in Group 2 were higher after revascularization. However, there were no differences between the 2 groups in arterial and hepatic venous HA levels. HA clearance by the graft also showed no differences between the groups. Although GOT reflected the degree of warm ischemia, HA and its hepatic clearance were not influenced by warm ischemic damage. In conclusion, HA was not thought to serve as a marker of liver injury when the graft suffered from warm ischemia.     

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

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.     

Dialysis in the treatment of renal failure in patients with liver disease

The value and effects of treating renal failure by dialysis are analyzed in a series of 84 patients with various types of liver disease. Although none of the 25 patients with cirrhosis survived, six of 50 with fulminant hepatic failure recovered completely as did seven of nine patients with renal failure secondary to extrahepatic biliary tract obstruction or with liver and renal damage following episodes of severe hypotension. Dialysis was required for seven weeks before diuresis occurred in one patient in the latter group. Both peritoneal and hemodialysis satisfactorily controlled plasma urea and creatinine levels, except in patients with fulminant hepatic failure in whom this was only achieved by hemodialysis. Complications of dialysis were most common in patients with cirrhosis and fulminant hepatic failure and included hypotension, gastrointestinal bleeding, and intraperitoneal sepsis. Overall, the results show that dialysis is only worth attempting in those patients in whom recovery of the underlying liver lesion is possible, and even then treatment for prolonged periods may be necessary.     

Surgical therapy for hepatocellular carcinoma with liver cirrhosis

Approximately 80% of hepatocellular carcinoma (HCC) patients in Japan have associated liver cirrhosis, which increases the difficulty of surgical treatment. Liver dysfunction associated with liver cirrhosis is one of the most important predictive prognostic factors for HCC patients. Percutaneous ethanol injection therapy (PEIT) is useful for patients with small HCC or with poor hepatic functional reserve. Transcatheter arterial chemoembolization (TACE) is also useful both for patients with unresectable HCC and patients with multiple intrahepatic recurrence. Liver resection, however, lead to better outcome than other treatments when liver function is maintained after surgery. To determine operative procedures, it is important to evaluate the exact function of remnant liver, based on the preoperative liver function test and the evaluation of tumor character. For advanced HCC patients with vascular invasion, non-surgical treatments such as PEIT or TACE are not indicated, and surgical intervention can be an effective modality to improve their survival. Improvements of surgical technique and perioperative management have decreased fatal complications at a major liver resection and allowed us to carry out liver resection on patients with advanced HCC.     

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

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.     

Prospective assessment of the hepatic perfusion index in patients with colorectal cancer

BACKGROUND: This prospective study was designed to test the hypothesis that abnormal liver blood flow is related to poor prognosis in patients with colorectal cancer. METHODS: The hepatic perfusion index (HPI), measured by dynamic hepatic scintigraphy, was assessed in 202 patients with colorectal cancer. Assessment for overt hepatic metastasis included liver palpation at laparotomy and perioperative computed tomography (CT). Follow-up at a dedicated clinic included regular abdominal ultrasonography and CT. RESULTS: The HPI was abnormal (greater than 0.37) in 92 (88 per cent) of 105 patients with overt liver metastases. Of 89 patients with no evidence of overt metastases or residual tumour after primary resection, 52 had an abnormal and 37 a normal HPI. At a median follow-up of 39 (range 13-76) months, 25 of 38 patients with recurrence had an abnormal HPI. Some 31 of 45 patients who died had an abnormal HPI. The HPI predicted overall recurrence (P=0.04, log rank test). Multivariate analysis showed the HPI was independent of Dukes stage for predicting disease-free survival (P=0.04, relative risk 1.94 (95 per cent confidence interval (c.i.) 1.03-3.67)) but this just failed to attain significance for overall survival (P=0.055, relative hazard 1.88 (95 per cent c.i. 1.00-3.58)). CONCLUSION: The HPI predicts a poor outcome in patients with colorectal cancer and may be useful in patient selection for adjuvant chemotherapy.     

Resection for extrahepatic recurrence of hepatocellular carcinoma

A total of 277 patients with hepatocellular carcinoma (HCC) underwent hepatic resection over a 20-year period. Twelve of 36 patients with recurrence confined to extrahepatic organs underwent surgical resection. There were no complications but one patient died in hospital from secondary intrahepatic recurrence. The 1-, 2- and 5-year survival rates for these 12 patients after hepatic resection were 92, 52 and 26 per cent respectively and were better than those of 24 patients who did not undergo resection for recurrence. The mean survival following resection for recurrent disease was 19.7 months and the longest survival time was nearly 8 years. Secondary recurrence after resection of metastases developed more commonly in the liver than in extrahepatic organs. Among the eight patients who survived for more than 4 months after the second operation, secondary recurrence developed in the liver and extrahepatic organs in eight and four patients respectively. In selected patients with isolated extrahepatic recurrence of HCC, surgery is effective in controlling extrahepatic disease and offers the only chance of long-term survival.     

Management of liver adenomatosis: results with a conservative surgical approach

Liver adenomatosis is defined by the presence of multiple hepatic adenomas (more than three lesions). The natural history and treatment of liver adenomatosis are not yet well defined. The Mayo Clinic (Rochester, MN) experience with liver adenomatosis in the past 11 years was reviewed and a rational treatment approach is presented. Records from patients with liver adenomatosis and hepatic adenoma seen at the Mayo Clinic from January 1986 to June 1997 were reviewed. Estrogen- and progesterone-receptor status was assessed by immunohistochemistry. Eight women with liver adenomatosis were identified. All patients had undergone surgical treatment. Abdominal pain was the presenting symptom in 87.5% of the patients with adenomatosis and in 42.1% of the patients with hepatic adenoma. Tumor bleeding was present in 62.5% of the patients with adenomatosis and in 26.3% of the patients with hepatic adenomas. Bleeding occurred predominantly in lesions greater than 4 cm. All patients with liver adenomatosis reported improvement of symptoms after surgery, and the mean bleeding-free period after resection in 5 patients was 52.6 +/- 23.6 months. In 6 patients, estrogen receptor-positive and estrogen receptor-negative tumors were identified in the same liver. Based on the good outcome after resection in symptomatic patients with liver adenomatosis, we recommend resection of large (>/=5 cm) or symptomatic lesions with observation of smaller lesions (相似文献   

Segmental liver resections for hilar cholangiocarcinoma

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.     

Cerebral oedema and increased intracranial pressure in chronic liver disease

BACKGROUND: Cerebral oedema is a cause of morbidity and mortality in fulminant hepatic failure but has not been well documented as a complication of chronic liver diseases. We report here the development of cerebral oedema and increased intracranial pressure in 12 patients with chronic liver disease. METHODS: Between July 1, 1987, and Dec 31, 1993, we studied 12 patients aged 29-67 years with end-stage chronic liver disease. All the patients had cirrhosis, portal hypertension, hypoprothrombinaemia, hepatic encephalopathy, and decreased serum concentrations of albumin (<25 g/L). During the study, the patients developed signs of increased intracranial pressure and had documented intracranial hypertension, cerebral oedema, or both. Intracranial hypertension was suspected on physical examination and confirmed by epidural catheters. We detected cerebral oedema by computed axial tomography of the head and necropsy of the brain when possible. FINDINGS: All the patients had intracranial hypertension and cerebral oedema. Two patients had successful treatment of cerebral hypertension with improvement of intracranial pressure such that orthotopic liver transplantation was undertaken. Both patients became neurologically normal after transplantation. Eight patients had only a transient response to treatment and died of cerebral oedema before a transplant could be done. INTERPRETATION: Cerebral oedema and increased intracranial pressure can occur in chronic liver disease and presents as neurological deterioration. Treatment guided by monitoring of intracranial pressure can lead to the reversal of intracranial hypertension, but in most patients cerebral oedema contributes to death or places them at too high a risk for liver transplantation.