Stimulation of alpha1A-adrenoceptors in Rat-1 cells inhibits extracellular signal-regulated kinase by activating p38 mitogen-activated protein kinase

We report a patient with cholangiocellular carcinoma with tumor thrombi in the main portal trunk who has survived for 9.5 years after hepatic resection. A 57-year-old woman underwent an extended left lobectomy, and resection of the caudate lobe plus the main portal trunk for a liver tumor that had a portal tumor thrombus in the main portal trunk. The portal vein was reconstructed with an autologous vein graft obtained from the external iliac vein. Histological examination of the resected specimen revealed moderately differentiated tubular adenocarcinoma compatible with cholangiocellular carcinoma. Factors contributing to the patient's long-term survival are discussed. Aggressive surgical resection can be effective even for such an advanced case of cholangiocellular carcinoma.     

Optic neuritis with residual tunnel vision in perchloroethylene toxicity

BACKGROUND: To identify and differentiate agenesis and severe atrophy of the right hepatic lobe on computed tomography (CT). METHODS: The CT examinations of three cases of agenesis and 11 cases of severe atrophy of the right hepatic lobe were reviewed. We evaluated visibility of the three hepatic veins, the two main portal veins (including their branches if necessary), the dilated intrahepatic ducts, enlargement of the medial and lateral segments of the left lobe and caudate lobe of the liver, presence of a retrohepatic gallbladder, hyperattenuation of the atrophic liver parenchyma, posterolateral interposition of the hepatic flexure of the colon, and upward migration of the right kidney. RESULTS: In the three cases of agenesis, no structure can be recognized as the right hepatic vein, right portal vein, or dilated right intrahepatic ducts. In the 11 cases of severe lobar atrophy, the right portal vein (or its branches) was recognized in eight cases, the right hepatic vein in four cases, and the dilated right intrahepatic ducts in 11 cases. The degree of enlargement of the lateral segment does not necessarily change inversely with the size of the medial segment and the caudate lobe. The retrohepatic gallbladder is present in eight cases (two in agenesis and six in atrophy). The phenomenon of hyperattenuation of the atrophic liver parenchyma was noted in six cases. CONCLUSION: Even though a retrohepatic gallbladder and a severely distorted hepatic morphology due to compensatory hypertrophy of the left and caudate lobes may raise a suspicion of agenesis of the right lobe of the liver, absence of visualization of all of the right hepatic vein, right portal vein and its branches, and dilated right intrahepatic ducts is a prerequisite of the diagnosis of agenesis of the right hepatic lobe on CT. In severe lobar atrophy, at least one of these structures is recognizable.     

Selective percutaneous transhepatic embolization of the portal vein in preparation for extensive liver resection: the ipsilateral approach

The ipsilateral approach was used at preoperative portal vein embolization in 38 patients with hepatobiliary malignancy. The right anterior portal branch was punctured. Two different 5.5-F triple-lumen balloon catheters were used, and fibrin glue and iodized oil were injected. Portal vein embolization was successful in all cases (right lobe, 24 patients; left lobe and right anterior segment, six; right lobe and left medial segment, three; right posterior segment, two; right anterior segment, one; left lobe, one; and right and caudate lobes, one).     

Hepatocellular carcinoma with portal vein tumor thrombus: embolization of arterioportal shunts

PURPOSE: To evaluate transcatheter arterial embolization in patients with hepatocellular carcinoma, portal vein tumor thrombus, and arterioportal shunts. MATERIALS AND METHODS: Ten patients with hepatocellular carcinoma, portal vein tumor thrombus, and severe arterioportal shunting were identified; in these patients, portal blood flow before embolization was hepatofugal. Embolization of arterioportal shunts was performed with steel coils that were introduced through a catheter during arteriography. After embolization, changes in portal hemodynamics and clinical signs and performance status of patients were evaluated; survival rates of patients with and patients without severe arterioportal shunting were compared. RESULTS: In all patients after embolization, angiography showed resolution of arterioportal shunting, and portography showed hepatopetal blood flow in the portal vein trunk. After embolization, performance status of five patients with initial scores of 2 or 3 improved. Ascites resolved in four patients and improved in four patients. One patient died of hepatic failure caused by rupture of esophageal varices 7 days after embolization. Median survival was 4.3 months, and the 6-month and 1-year survival rates were 45% and 12%, respectively. There were no significant differences between survival rates in patients with and patients without severe arterioportal shunting. CONCLUSION: Transcatheter arterial embolization of arterioportal shunts is a useful treatment for improving quality of life in patients with hepatocellular carcinoma.     

Left trisegmentectomy for hepatocellular carcinoma with tumor thrombi extending to the third branches in the remnant liver

BACKGROUND/AIMS: A successful left trisegmentectomy and tumor thrombectomy for hepatocellular carcinoma (HCC) of the right third branches in the remnant liver is described. METHODOLOGY: In this case, the hepatocellular carcinoma originated in the internal segment of an HBs- and HBe-Ag positive cirrhotic liver, involved the portal vein of the umbilical portion across the portal trunk to the contralateral third branches, and had many metastatic nodules in the anterior segment of the liver. To remove tumor thrombi by directly visualizing the lumen of the third branches of the portal vein, the portal trunk to the anterior branch of the portal vein was completely isolated by transecting the hepatic parenchyma along the intersegmental plane through a hilar approach. Tumor thrombi were removed by incising the portal trunk toward the anterior branch of the portal vein. Portal flow to the remnant liver was restored preceding liver resection to preserve hepatic function. After division of the anterior Glissonean code, the left trisegment and caudate lobes of the liver were resected. RESULTS: The patient was discharged 10 weeks after surgery and remained well for the first six months thereafter. Recurrent tumors, however, appeared in the remnant liver 7 months after surgery. CONCLUSIONS: This procedure may be applicable in cases of HCC with portal tumor thrombi extending into the third branches in the remnant liver.     

Testosterone concentrations, testes weight and morphology of mule drakes (Muscovy drake x Khaki Campbell)

BACKGROUND: Transjugular intrahepatic portosystemic shunts (TIPS) are sometimes used to reduce the risk of variceal bleeding or treat intractable ascites before orthotopic liver transplantation (OLT). TIPS usually do not make OLT more difficult, but rarely, malposition of TIPS can significantly complicate OLT. METHOD and RESULTS: The following report describes a patient in whom an initially well-placed Wallstent migrated to the confluence of the splenic and superior mesenteric veins. During liver transplantation, the portal vein containing the Wallstent was completely resected, and the portal vein was reconstructed with donor iliac vein. After sewing the iliac vein onto the portal remnant, the liver transplant was completed under portosystemic bypass. The patient had an uneventful recovery. CONCLUSIONS: Wallstents can migrate within the portal vein. An interposition graft of donor vein allows full resection of the portal vein containing a migrated stent and facilitates portosystemic bypass and portal anastomosis.     

Hypogenesis of right hepatic lobe accompanied by portal hypertension: case report and review of 31 Japanese cases

We report a rare case of hypogenesis of the right lobe of the liver with portal hypertension and a review of 31 cases of agenesis or hypogenesis of the right hepatic lobe reported in Japan. A 74-year-old man consulted our hospital for further examination after a mass screening for gastric cancer. On physical examination liver enlargement was palpable, but liver function tests were normal. Abdominal ultrasonography, computed tomography, technetium-99m liver scintigraphy, and endoscopic retrograde cholangiopancreatography revealed a small right hepatic lobe and moderate splenomegaly, in contrast to a hypertrophic lateral segment of the left hepatic lobe, as well as ectopic dislocation of the gallbladder. Endoscopic examination revealed esophageal varices, indicating portal hypertension. Abdominal angiography demonstrated mild shunt flow between the hepatic artery feeding from the gastroduodenal artery and the portal vein. A biopsy specimen taken from both lobes of the liver showed normal liver tissue histologically. Based on these findings, we made a definite diagnosis of hypogenesis of the right lobe of the liver with portal hypertension. The present case appears to be the first such case accompanied by portal hypertension reported in Japan.     

Decreased interleukin-7 and transforming growth factor-beta1 levels in blister fluids as compared to the respective serum levels in patients with bullous pemphigoid. Opposite behavior of TNF-alpha, interleukin-4 and interleukin-10

Prognosis of hepatocellular carcinoma (HCC) patients with tumor thrombi (TT) in the trunk of the portal vein (PV) has been extremely poor. There have been few reports of long-term survivors with such an advanced condition. In this article, the case of a 62-year-old woman of HCC, who survived for 6 years and 9 months after an operation, with TT in the trunk of the PV is described. The patient not only had a primary tumor of 4 cm in diameter with TT but also multiple intrahepatic metastases in the bilateral lobe of the liver. A palliative lateral segmentectomy with tumor thrombectomy through the incised left first branch of the PV was performed. Moreover, an intraoperative ethanol injection for residual intrahepatic metastatic tumors was performed subsequently. Hepatic arterial infusion of anti-cancer drug with Lipiodol, intraportal continuous infusion of 5-FU and percutaneous ethanol injection therapy were performed suitably during the follow-up periods. The patient survived for 6 years and 9 months after operation and died of hepatic insufficiency with cancer. In this case a patient who suffered from HCC with TT in the trunk of the PV was successfully treated by multimodality procedures including hepatic resection with tumor thrombectomy.     

New perspectives on the clinical applications of functional radiology of the liver

Preliminary results of "new clinical applications" of functional imaging of the liver are reported. In 20 healthy volunteers portal flow measurement with Doppler US at the level of right, left portal branch and main portal trunk, showed the preferential distribution in baseline conditions of portal flow to the right liver (about 68%) as compared to the left portal branch. This influenced MRI volumetry of right liver as compared to left liver. After meal intake, flow increase was significantly higher at the level of left portal branch suggestive for a "functional reserve" in left liver. Portal flow physiology was examined in preparation of portal imaging before and after portal vein embolization, a procedure performed preoperatively before enlarged hepatectomies.     

Two-step portal bypass to reconstruct an invaded superior mesenteric vein in pancreatic cancer

Advanced cancer of the pancreatic head, especially in its caudal portion, has a limited surgical resectability due to its frequent invasion to the superior mesenteric vein (SMV). A patient with advanced carcinoma of the pancreatic head with vascular invasion to the major bifurcation of the SMV, underwent a pancreatico-duodenectomy under a two-step passive bypass of the portal flow. The marginal colic veins were dilated and formed a long collateral route to the inferior mesenteric vein and the splenic vein due to stenosis of the SMV. The venous flow in this vein was then easily interrupted with the surgical manipulation of the transverse colon. The first passive bypass was thus inserted into the accessory right colic vein to preserve the venous return from both the small intestine and the colon, and also to enable surgical dissection of the invaded SMV itself. After a thorough dissection of the invaded SMV, a second bypass was inserted into the main trunk of the SMV through the dissected vascular stump. Subsequently the passive bypass was maintained until the portal reconstruction with an interposition of the left common iliac vein could be performed. The patient recovered well from the surgery without any complications throughout the postoperative course. In summary, the two-step portal bypass describes, is thus considered a stable and safe procedure for the reconstruction of the superior mesenteric vein, during pancreatoduodenectomy for advanced carcinoma of the pancreatic head.     

Immediate increase in arterial blood flow in embolized hepatic segments after portal vein embolization: CT demonstration

OBJECTIVE: This study was conducted to determine whether an immediate change occurs in the blood flow distribution in hepatic segments after segmental portal vein embolization. CONCLUSION: We found an immediate change in the distribution of blood flow in the liver after embolization; with portal vein embolization, we found an immediate increase in the hepatic artery blood flow in the affected segments.     

Vascular resection during surgical resection for advanced gallbladder carcinoma

We evaluated the results of vascular resection during surgical resection for advanced gallbladder carcinoma. Twelve patients underwent vascular resection (portal vein in 11, hepatic artery in 2, inferior vena cava in 2) in 58 resected patients with advanced gallbladder carcinoma (stage III and IV). The surgical rate was higher in the nonvascular resection group (61%) than in the vascular resection group (25%) (p < 0.05). Surgical morbidity and mortality rates were not significantly different between the two groups. The survival rate was remarkably higher in the curative resection group (n = 29) (55.6% at 1 year, 30.3% at 3 years, 20.8% at 5 years) than in the noncurative resection group (n = 29) (26.3% at 1 year, 0% at 2 years) (p < 0.05). Survival rates of the nonvascular resection group (n = 46) were 45.3% at 1 year, 23.4% at 3 years, and 16.1% at 5 years. However, no patient in the vascular resection group (n = 12) survived longer than 2 years. In conclusion, vascular resection during surgical resection for advanced gallbladder carcinoma does not result in a more favorable prognosis, despite similar surgical risk as in nonvascular resection procedures.     

Interventional radiology in the treatment of primary and metastatic liver cancer

The data available in the literature and the authors' own treatment outcomes in 600 patients with primary and metastatic carcinoma of the liver (in 1983-1996) were analyzed. Systemic or intravascular therapy as regional drug infusion, embolization, chemoembolization of the hepatic artery (CEHA) and portal vein (CEPV) was performed in unresectable cases. Whether pre- and postoperative chemoembolization was evaluated in resectable tumors. It is concluded that X-ray endovascular interventions play an important role in the treatment of malignant hepatic tumors. Transcatheter CEHA alone and in combination with CEPV is the most effective current treatments of unresectable carcinoma of the liver. In some patients, preoperative CEHA makes it possible to remove the tumor previously considered to be unresectable. Resection in combination with adjuvant CEHA and CEPV reduces the incidence of postoperative recurrences. The combined approach to treating malignant hepatic neoplasms expands the possibilities of delivering care to patients and improving late outcomes.     

Quantitative determination of spleen added to ground beef

Simultaneous measurement of cardiac output distribution with 86Rubidium and 57Cobalt-tagged microspheres in rats implanted with liver tumors by intraportal injection of sarcoma cells enables quantitation of arterial and portal tumor circulation. The portal circulation was found to be increased in small tumors as compared to the liver, but as the tumor grew there was a decrease in the portal tumor circulation. When the tumor growth became massive even the total liver circulation was reduced, as measured with 133Xenon wash-out. All the tumors had increased arterial circulation. This arterial hyperperfusion was changed into ischemia when the liver artery was occluded through embolization with degradable microspheres.     

Pharmacokinetics and amoebicidal activity of (+-)-(E)-3-(4- methylsulphinylstyryl)-1,2,4-oxadiazole (BTI 2286E) and its sulphone metabolite (BTI 2571E) in the golden hamster, Mesocricetus auratus

We studied, clinically and experimentally, hypertrophy of the part of the liver not embolized after portal vein embolization (PVE). The subjects of the clinical study were 29 patients with hepatocellular carcinoma (HCC) who underwent embolization of the right first portal branch; 19 patients had cirrhosis, and 10 did not. The volume of the liver was calculated from computed tomograms obtained before PVE and 2 weeks after. In all patients, the volume of the nonembolized (left) lobe increased significantly. For the experimental study, we used male Wistar rats. Normal rats were untreated, and in the other rats cirrhosis was induced with carbon tetrachloride. The portal branch that supplies 70% of the total volume of the liver was embolized. The rats underwent one of four procedures: 70% PVE, 70% portal vein ligation, 70% hepatectomy, or laparotomy only. Rats wre killed at different times after surgery, and the livers were removed and weighed. The mitotic index and DNA synthesis were measured in the nonembolized lobe (PVE group), in the lobe not supplied by the ligated branch (ligation group), or in the remaining liver (hepatectomy group). The liver weight, mitotic index, and DNA synthesis were high in the PVE, ligation, and hepatectomy groups for both normal rats and rats with cirrhosis. PVE caused cell proliferation and hypertrophy in the nonembolized part of the liver in the normal rats and even in those with cirrhosis. We concluded that PVE can extend the surgical indications for patients with HCC and underlying cirrhosis.     

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.     

The transjugular stent implantation for the treatment of malignant portal and hepatic vein obstruction in cancer patients

BACKGROUND: The increase in portal vascular resistance is a significant complication of metastatic disease to the liver or locally advanced cancer, e.g., biliary cancer. PATIENTS AND METHODS: This paper describes the successful palliative treatment of two cancer patients with portal hypertension presenting with the symptoms of tense ascites, mesenteric congestion, and severe variceal bleeding. By creating a stenttract between a hepatic vein and a main branch of the portal vein and/or by placing an extendable stent into the portal vein, the transjugular intrahepatic portosystemic stent-shunt (TIPS) technique was used to decompress the portovascular system. RESULTS: The TIPS-technique offers a new, safe and effective palliation for malignant portal hypertension. In both patients, the symptoms of the portal hypertension disappeared after the procedure. This was accompanied by a significant improvement of the patients performance status allowing an early ambulation. CONCLUSION: Our findings demonstrate the feasibility and effectiveness of the TIPS procedure as a minimal invasive treatment for portal vein decompression in selected tumor patients.     

High serum alpha-fetoprotein concentration associated with pseudoinfarction of a cirrhotic liver: report of a case

We report herein the case of a 65-year-old man with cirrhosis of the liver in whom a portal vein thrombus was found to be the cause of a marked elevation in serum alpha-fetoprotein (AFP). The patient presented with fever and abdominal pain, and a diagnostic work-up revealed a liver mass and an increased serum AFP concentration of 91,000 ng/ml. The mass gradually regressed, and the AFP concentration simultaneously decreased to 163 ng/ml. However, because hepatocellular carcinoma (HCC) could not be ruled out, a partial hepatectomy was performed. Histological examination of the resected specimen revealed a thrombus of the portal vein surrounded by the fibrosis associated with liver cirrhosis, but no neoplastic lesion was found. Thus, portal thrombus associated with liver cirrhosis might induce an extremely high level of AFP production.     

Hepatic resection for advanced carcinoma of the gallbladder

Hepatic resection for advanced carcinoma of the gallbladder must be decided upon based on the modes of cancer spread to the liver. The cystic vein through the liver bed is considered an important route of liver metastasis, because liver metastases of gallbladder carcinoma are found frequently around the liver bed. About 70% of early metastatic foci demonstrated microscopically occur in segments 4a and 5. Resection of segments 4a and 5 is considered to be an adequate range of hepatectomy for patients with subserosal invasion, because early metastatic foci are detected not only in patients with direct invasion of the liver but also in those without direct invasion. For patients with direct liver invasion, various degrees of hepatic resection are needed to comply with the depth of direct invasion. It is necessary to achieve negative surgical margins 2 cm from the tumor. Because cancer cells extend along the Glissonian sheath in patients with hilar invasion, extended right hepatectomy with caudate lobectomy is required in these patients. A future problem is to establish the safety of extended hepatectomy in these patients.     

Bromodeoxyuridine uptake by early liver metastases in rats: a comparison of the hepatic artery and portal vein infusion routes

Liver metastases generated by the intraportal inoculation of ascites hepatoma cells in Donryu rats were labeled with bromodeoxyuridine (BrdU) through the hepatic artery, or through the portal vein with or without ligation of the hepatic artery, 3, 6, or 9 days after tumor inoculation. The distribution of BrdU-labeled cells was evaluated in 174 metastases, 110-1640 microm in diameter, by immunohistochemical methods. When a dual blood supply from the portal vein and hepatic artery existed, the BrdU-labeled cells were diffusely found in the metastases regardless of their size and the route of BrdU infusion. When blood supply to metastases larger than 610 microm in diameter was from a single source, namely the portal vein, the BrdU-labeled cells were located within 90-290 microm from the margin of the metastases. These results indicate first, that drug uptake by the inner part of the early metastatic liver tumors is achieved through the hepatic artery, and second, that drug uptake by early liver metastases through the portal vein is limited to within the extent of portal diffusion regardless of the size of the metastases. Thus, we conclude that prophylactic treatment against liver metastases would be more effective when given via the hepatic artery route rather than via the portal vein route.