Tropical liver abscess

Forty-one consecutive cases of liver abscesses seen at the National University Hospital, Singapore from 1988 to 1994 were reviewed. Twenty-seven cases (65%) were pyogenic, six (15%) amoebic, two (5%) tuberculous and six (15%) indeterminate. The predominance of pyogenic abscesses is in marked contrast to previous studies from the region a decade ago in which amoebic abscesses were the commonest type. The commonest pathogen causing pyogenic abscess was Klebsiella pneumoniae. Two cases were due to Mycobacterium tuberculosis, and this organism needs to be actively looked for in smears and cultures of aspirated material. As the majority of organisms isolated were resistant to ampicillin, empirical antibiotic treatment for suspected pyogenic abscess should include gentamicin or a cephalosporin. Percutaneous needle aspiration of the abscess was performed for 85% of pyogenic abscesses and surgery was necessary in only two cases because of complications. We found that percutaneous aspiration of liver abscess is helpful to confirm the diagnosis, provides a better bacteriological culture yield, gives a good outcome, and may uncover clinically unsuspected conditions like malignancy and tuberculoma which may mimic the presentation of liver abscesses. We recommend routine cytological examination of aspirated abscess material as well as stains and cultures for acid-fast bacilli.     

Synthesis of pteroylpolyglutamates in rat liver during regeneration after partial hepatectomy

The liver content of higher polyglutamate forms of folic acid, which in partially hepatectomized rats is markedly lower as compared with sham operated animals, is normalized by the vitamin administration. The greater availability of folic acid and consequently of the tetrahydrofolates, promotes the synthesis of actual coenzymic forms; so their content, in regenerating liver, is maintained at normal values in spite of a higher requirement caused by the exaltation of biosynthetic processes.     

Lysosomal enzyme beta-glucuronidase. Release from regenerating liver after partial hepatectomy

In 12 dogs, 70% hepatectomy was performed to investigate the changes in serum lysosomal enzyme beta-glucuronidase activities, and to compare them with other liver functions and with the restoration of liver mass. Three dogs died within 24 hours without recovering consciousness from anesthesia, and one died on the fourth postoperative day because of hepatic insufficiency. The other eight dogs were killed at various postoperative times up to eight weeks. Regeneration of the remaining liver occurred rapidly after operation. The peak elevation of serum glutamic oxaloacetic transaminase activity was found on the first postoperative day, with a steady return to normal within two or three weeks. To the contrary, the serum activity of beta-glucuronidase decreased during the first three days, but increased substantially between the seventh and 14th postoperative day, when regeneration was considered to be maximum. The results seem to indicate that serial determinations of lysosomal enzyme activities in the blood can be a beneficial biochemical index for detection of progressing liver regeneration following partial hepatectomy.     

Synthesis of secretory protein in regenerating liver of rat after partial hepatectomy

Albumin immunoreactivity in the liver was examined on days 2, 5 and 10 after two-thirds partial hepatectomy by light and ultrastructural immunoperoxidase methods and the ultrastructural area of the rough endoplasmic reticulum (ER) in hepatocytes was measured. Albumin immunoreactivity was seen in the rough ER and Golgi apparatus of all hepatocytes in the hepatectomized liver and ultrastructural analysis showed a significantly greater area of rough ER on day 5 than on days 2 or 10. Albumin mRNA was studied by the in situ hybridization technique using radioisotopes and their numbers were determined visually. Albumin mRNA was present as grains in all hepatocytes and the grains varied in number during regeneration of the liver, being more abundant on day 5 than on days 2 or 10. The activity of [3H]-leucine incorporated into albumin synthesis, an indicator of translational activity, was higher on days 5 and 10 than on day 2 and was highest on day 5. In conclusion, albumin synthesis varied during liver regeneration after partial hepatectomy, being reduced at the peak of cell proliferation on day 2 and being most active on day 5.     

Partial hepatectomy or orthotopic liver transplantation for the treatment of resectable hepatocellular carcinoma? A cost-effectiveness perspective

BACKGROUND: Na+/H+ exchange plays an important role in the ionic changes observed during myocardial ischemia and reperfusion. We investigated the cardioprotective efficacy of a selective Na+/H+ exchange inhibitor, 4-isopropyl-3-methylsulfonyl-benzoylguanidin-methanesulfonate (HOE642), in a canine model of long-term heart preservation. METHODS: Canine donor hearts were stored for 24 hours in hyperkalemic crystalloid cardioplegic solution; in cardioplegic solution enriched with HOE642; in cardioplegic solution enriched with HOE642, with donor and recipient treated with HOE642; in standard cardioplegic solution, with donor and recipient treated with HOE642; or in standard cardioplegic solution, with only the recipient treated. After orthotopic transplantation, pressure-volume relationships were obtained and dogs were weaned from bypass. Morphology was studied. RESULTS: Myocardial compliance was well preserved when donor and recipient were treated. These groups had the lowest myocardial water content, and no morphologic signs of irreversible damage. In these groups, weaning from cardiopulmonary bypass was successful in 10 of 10 animals, with a cardiac index around 2 L x min(-1) x m(-2). Only 3 of 5 animals in each of the other three groups could be weaned, with significantly lower cardiac indices. CONCLUSIONS: Treatment with HOE642 in both donor and recipient improves myocardial compliance, postweaning cardiac index, and ultrastructure of donor hearts preserved for 24 hours and orthotopically transplanted.     

Effect of RES on liver regeneration and survival after 90% partial hepatectomy

In previous studies, 90% partial hepatectomy in the rat was invariably accompanied by 100% mortality within 40 hr. This paper describes the effect of enhanced reticuloendothelial system (RES) on liver regeneration after 90% partial hepatectomy. RES was activated using 5 K.E. of OK-432 injected intraperitoneally 24 hr before 90% partial hepatectomy. Ninety per cent of the liver mass was resected and rats were provided with tap water or 20% glucose orally and subcutaneously. Survival time was strikingly different. In rats provided with tap water only; 100% of rats died before 42 hr. In rats provided with 20% glucose; 44.2% of rats survived beyond 42 hr. In rats pretreated with OK-432 and provided with 20% glucose; 87.0% of rats survived beyond 42 hr. This regimen results in severe hypoglycemia and dead within 42 hr. When RES was activated before 90% partial hepatectomy, significantly higher blood glucose level was observed. BrdU labeling index was significantly higher in rats pretreated with OK-432 than in control rats. The results indicate that enhancement of RES before 90% partial hepatectomy provides acute metabolic support and enhancement of liver regeneration resulting in improved survival.     

Donor hepatectomy for living-donor liver transplantation

Between September 1993 and November 1996, donor hepatectomy was performed in 22 living donor liver transplantation at Queen Mary Hospital, Hong Kong. In these donor operations, 7 extended right lobe grafts, 6 extended left lobe grafts and 9 left lateral segment grafts were obtained. The technique of donor operations consisted of initial hilar dissection, mobilization of the liver lobe, transection of the liver using ultrasonic dissector (without inflow or outflow vascular occlusion) at a plane on the left side of the middle hepatic vein for an extended right lobe graft, on the right side of the middle hepatic vein for an extended left lobe graft or on the right side of falciform ligament for a left lateral segment graft. The median blood loss was 775 ml. Complications occurred in 2 donors: one had incisional hernia and the other had biliary stricture. Both were treated successfully by re-operation. Currently all donors are well with completely normal liver biochemistry.     

Mitosis and apoptosis in the liver of interleukin-6-deficient mice after partial hepatectomy

Six core-penetrating Rydberg series have been assigned in the CaCl molecule by a combination of double-resonance spectroscopic techniques. Two 2Sigma+ series, with approximate quantum defects (delta) of 0.51 and 0.25, have been observed with effective principal quantum numbers (n*) in the range of 5-8 using the D2Sigma+ state as the resonant intermediate state for REMPI and/or ion-dip detection. A third 2Sigma+ series with delta approximately 0.84 and a 2Delta series with delta approximately 0.95 have been observed with n* = 16-18 using the A2Pi3/2 state as the resonant intermediate state for preparation of v+ = 1 vibrationally autoionizing states. Two additional series in the same region with delta approximately 0.90 and 0.07 are tentatively identified as the expected core-penetrating 2Pi series. Vibrational assignments have been confirmed in many cases on the basis of isotope shifts between the 35Cl and 37Cl isotopomers. The ion-dip and REMPI spectra display linewidths systematically broadened by predissociation. In addition to the assigned core-penetrating series, both the REMPI and the ion-dip spectra display some sharper features that have not yet been assigned. These sharper features most likely arise from perturbations of optically "bright" core-penetrating states by nominally "dark" higher-l core-nonpenetrating states. Copyright 1999 Academic Press.     

Randomized study of chemoembolization as an adjuvant therapy for primary liver carcinoma after hepatectomy

From April 1990 to December 1993, 140 patients were recruited to a randomized study to evaluate transcatheter hepatic arterial chemoembolization (TACE) as an adjuvant therapy for primary liver carcinoma after hepatectomy. This study investigated the principle, techniques and results of TACE. The results showed that the intrahepatic recurrence rate was 48.9% in the patients who underwent radical resection only, but only 21.3% in the patients who also underwent TACE 3-4 weeks after hepatectomy (P < 0.01). The 1-, 2-, 3-, and 4-year survival rates were 72.3%, 52.7%, 35.1%, and 35.1% respectively for the patients who underwent radical resection only, and were 97.9%, 85.5%, 69.5%, and 56.9% for the patients who also underwent TACE 3-4 weeks after radical resection (P < 0.001). The 1-, 2-, 3-, and 4-year survival rates were 38.9%, 0%, 0%, and 0% for the patients who underwent palliative resection only, and were 68.3%, 32.3%, 21.5%, and 21.5% respectively for the patients undergoing TACE 3-4 weeks after palliative hepatectomy (P < 0.001).     

Partial orthotopic liver transplantation

From October 1990 to May 1992, nine of 38 patients with liver transplants (24%) had partial orthotopic liver transplantation on account of lack of size-matching donor livers. The preliminary results have presented very few problems; there was no per- or postoperative mortality and no surgical complications. Four patients had episodes of acute rejection which responded to anti-rejection therapy, and two patients were treated for CMV infection. All patients are discharged with normal liver function 4-9 weeks after transplantation (median 5 weeks). The method seems to be safe and can be used in centers with limited activity, where there is a problem of having the correct liver at the correct time.     

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.     

Changing management of pyogenic liver abscess

The case records of 23 patients who presented over a 5-year period with a diagnosis of pyogenic liver abscess were reviewed. Ascending cholangitis was implicated in nine cases, seven of which were associated with underlying malignancy. Haematogenous spread via the portal route accounted for five cases. Primary treatment included percutaneous abscess drainage in 15 patients. Whereas nine of the 11 patients with benign underlying pathology were managed successfully, the four with malignant biliary obstruction did not survive. Only one of the 23 patients who presented with hepatic abscess required surgical intervention. Percutaneous abscess drainage combined with appropriate antibiotic therapy is an effective means of managing hepatic abscess, but there remains a substantial overall mortality rate resulting from the increasing incidence of malignant biliary obstruction as a cause of this condition.     

Rat peripheral mononuclear cell thymidine kinase activity increases during liver regenerative processes after partial hepatectomy

Deoxythymidine kinase (TK; EC 2.7.1.21) activity in the liver has been used as a marker of liver regeneration after partial hepatectomy. In this study we examined TK activity of various organs, plasma and peripheral blood mononuclear cells (PMNC) in 70% partially hepatectomized rats. TK activity of lymph nodes, small intestine, heart, lung, kidney and thymus did not increase significantly during the course of the study, except for spleen at 72 h. On the other hand, PMNC-TK and liver cystosolic TK activity increased in a parallel fashion at all times after partial hepatectomy; they began to increase 12 h after surgery and peaked 48 h post-surgery. Fractionation of PMNC into T cells and B cells revealed that both populations increased and peaked 48 h post-surgery. Plasma TK peaked 12-24 h after surgery, then declined at 36, 48 and 72 h after partial hepatectomy. This change paralleled plasma levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT). PMNC-TK activity correlated significantly with liver cystosolic TK activity 24 h (r = 0.743; P < 0.05) and 48 h (r = 0.708; P < 0.05) after partial hepatectomy. However, it did not correlate with plasma levels of TK, AST and ALT. The results indicate that in the early stage of liver regeneration PMNC-TK may provide a marker of liver regenerative processes.     

Amebic liver abscess of unusual presentation

A 35-year-old male who had travelled extensively in the tropics presented with severe anorexia and vomiting associated with fever of 39-40 degrees C during a 4-day period. The clinical findings were entirely negative. In 1973, he had been given metronidazole for amebic dysentery, since when recurrent attacks of diarrhea and abdominal pain had been treated with iodoquinoleines. Stool examination was negative for amebae. Liver scan revealed a suspect "expansive process" in the right lobe. The presumptive diagnosis of amebic abscess was made and metronidazole therapy was started. In less than 24 h the patient became afebrile. The abscess was confirmed by a further liver scan. The definitive diagnosis of amebiasis was established 16 days later when the immunofluorescence level, which had been previously negative, became positive 1/480. This case demonstrates the dangers of the indiscriminate use of iodoquinoleines in patients who have travelled in tropical countries. The amebic liver abscess may be silent locally while causing systemic manifestations such as fever. Early treatment of hepatic amebiasis is recommended even with a presumptive diagnosis. Serological tests during the development of an amebic abscess may be negative and should be repeated after several days of therapy.     

Intrahepatic gas formation without abscess after hepatic artery thrombosis in the setting of liver transplantation

This paper reports that lesions of the medial frontal cortex (MFC) caused behavioral deficit in rats and that this deficit could be attenuated by a well formulated treatment with Org2766, an analog of ACTH-(4-9). Wistar rats were distributed in 3 groups: MFC lesion treated with saline (M-N); MFC lesion treated with Org2766 (M-O); and sham-operation treated with saline (S). Repeated Org2766 or saline injection commenced from the day of surgery and lasted for 13 days. After surgery, the rats were trained in a passive avoidance task and then in an active avoidance task. MFC lesions were found to be strongly associated with behavioral deficits. The M-N group rats displayed poor retention of the passive avoidance response and showed much slower learning of the active avoidance task as compared to S group rats. The result showed that chronic Org2766 administration improved the behavioral performance of both tasks in MFC lesioned rats. The also revealed that the superoxide dismutase (SOD) activity was significantly increased in the M-O group as compared to the M-N group 15 days after surgery. The possible mechanisms related to the beneficial effect of Org2766 on cortex damage are discussed.