- Email: [email protected]
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Vol. 7, No. 2 2003
nodal positivity, synchronous versus metachronous presentation, and extent of hepatic resection (lobectomy or greater resection versus lesser R/As). Conclusion: Hepatic control by R/A is adversely affected by increasing number of lesions and procedures required to clear disease.
Abstracts
285
non-simultaneous HBAL. Each BAL treatment lasted 6 hours. The common state of the patients and the biochemical indexes were studied. Results: After treated with bioartificial liver, ammonia, prothrombin time and total bilirubin index showed significant decrease. 2 days later, only ammonia still showed significance. In one month period, 1 case (1/7) in simultaneous group died while in non-simultaneous group 2 cases (2/5) died. Significance was shown in two groups. The total mortality rate was 25%. Conclusions: The constructed bioartificial liver can support liver functions in acute liver failure. The simultaneous HBAL is better than non-simultaneous HBAL.
89 Focal Adhesion Kinase Signaling in Hepatic Regeneration Carol P Bowen, Reid B Adams, University of Virginia Health System, Charlottesville, VA
87 Laparoscopic Management of Benign Hepatic Cysts and Cystic Neoplasms Robert E Glasgow, Michael D Rollins, Sean J Mulvihill, University of Utah, Salt Lake City, UT Benign cystic lesions of the liver include a wide spectrum of disease processes, including benign simple cysts, polycystic disease, and cystic neoplasms. The purpose of this video presentation is to illustrate the laparoscopic approach to benign cystic lesions of the liver. In this presentation, the laparoscopic treatment of a simple hepatic cyst, fenestration of polycystic liver disease, and excision of a giant hepatic mucinous cystadenoma will be demonstrated. Principles of laparoscopic treatment of benign cystic lesions include adequate preoperative imaging and the routine use of intraoperative laparoscopic ultrasound. We routinely use three to four trocars and a 30 or 45 degree laparoscope. Cyst and hepatic parenchymal division is performed with the Harmonic scalpel and electrocautery. For simple hepatic cysts, the cyst wall is excised such that at least 50% of the diameter of the cyst is unroofed. For cysts with a large intrahepatic component, the omentum is mobilized and placed within the cyst to facilitate closure. For polycystic liver disease, cysts are unroofed, resected, and/or fenestrated. If biliary communication is identified, the involved duct is suture ligated from within the cyst cavity. For cystic neoplasm, laparoscopic enucleation and resection are performed. Intraoperative frozen section evaluation of the cyst wall for malignancy is necessary. The postoperative course is similar to that for laparoscopic cholecystectomy. In summary, benign hepatic cysts and cystic neoplasms are effectively treated with a laparoscopic approach.
LIVER Other 88 The Development of a New Bioartificial Liver and its Application in 12 Acute Liver Failure Patients Yitao Ding, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China Background: Bioartificial liver is a hope of supporting liver functions in acute liver failure patients. Using polysulfon fibers, a new bioartificial liver was developed. The aim of this study was to show whether this bioartificial liver could support liver functions or not. Material and methods: Hepatocytes were procured from swine using Seglen’s methods. The bioartificial liver was constructed by polysulfon bioreactor and more than 1010 hepatocytes. It was applied 14 times in 12 patients, who were divided into 7 cases of simultaneous HBAL and 5 cases of
Introduction: The liver has considerable ability to regenerate in response to injury of many types. Following partial hepatectomy (PH), a rapid and specific series of biochemical events occur prior to cellular proliferation. Maximum DNA synthesis occurs within 24 hours of PH and regeneration is completed by 10 days. Post resection c-Jun, c-fos and liver regenerating factor-1 (LRF-1) mRNA levels are elevated within 30 minutes of the procedure. One critical regulator of cellular proliferation is adhesion mediated signals. These are regulated by focal adhesion kinase (FAK) following its activation by the interaction of integrins with the extracellular matrix. Yet the role of FAK and other adhesion signal mediators are unknown in liver regeneration (LR). Activated FAK results in increased cell motility, proliferation and suppresses apoptosis, all important in organ regeneration. We hypothesized that FAK would play a pivotal role in LR as evidenced by elevated protein levels and activation following resection. Method: Balb/C mice were divided into four treatment groups. (1): 24 hours after sham PH (n6), (2): 1 hour after 1/3 PH (n6), (3): 24 hours after 1/3 PH (n6) and (4): 288 hours after 1/3 PH (n2). All animals had a general anesthetic, a midline laporatomy and procedure noted above performed. At the study time indicated, the remainder of the liver was removed. A second group of animals underwent 1/3 PH, then at 1, 5, 10, 15, 30, and 60 minutes later, the remaining liver was resected. Liver cell lysates were analyzed by immunoblotting for FAK expression and activation. Results: FAK (total and activated) is downregulated in the post resected samples as compared to pre resection at 1 hr, 24 hrs and 288 hours. As this was unexpected, we analyzed the FAK family protein PYK2, and found its expression inverse to that of FAK. Activated FAK is increased very early after PH (maximum at 5-10 min), and then returned to baseline, whereas PYK2 stayed elevated until 30 minutes post resection and decreased to normal by 60 minutes. Downstream effectors of adhesion signaling also were activated early. Conclusion: LR stimulates changes in adhesion mediated signals, suggesting their involvement in hepatic growth. Regulation is early, within minutes, with FAK transiently increasing before being suppressed, whereas its related family member, PYK2 is upregulated for a more sustained time after PH. Further studies are warranted to elucidate the role of adhesion signaling in LR and hepatocellular carcinogenesis.
90 Resection for Symptomatic Hepatic Cysts: Is It Worthwhile? Yu-Meng Tan, London Lucien Ooi, Alexander Y Chung, Chow K Pierce, Lay Wai Khin, Singapore General Hospital, Singapore, Singapore; National Medical Research Council, Singapore, Singapore Background: Symptomatic liver cysts can be managed surgically by fenestration or by hepatic resection. Although fenestration procedures are preferred, this is associated with a higher recurrence rate. Conversely, hepatic resections are rarely associated with recurrence and are becoming a safer procedure in specialised units. Methods: 40
286
Journal of Gastrointestinal Surgery
Abstracts
patients with symptomatic liver cyst (non-parasitic and non-malignant) surgically treated by fenestration or resection were identified from a prospectively collected database. A retrospective analysis of primary outcome measures including operative parameters, morbidity and mortality rates, length of post-operative stay and recurrence rates in months was carried out to determine the better treatment option. Results: 27 patients had undergone fenestration (17 by open method and 10 by laparoscopic method) and 13 patients had undergone resection for treatment. Cyst and patient parameters were comparable in all three treatment arms. There was no mortality in our series. Morbidity was less in the fenestration group but in the resection group morbidity was mainly for minor complications like wound infection, chest infection and paralytic ileus. At median follow-up of 20 months, there were no recurrences in the resection group but 6/27 (22%) in the fenestration groups (3 in laparoscopic and 3 in open fenestration). Two required a hepatic resection and the other four were observed as they were asymptomatic radiological recurrences. Conclusion: The best result for our patients was obtained with resection. Although it was associated with a longer post-operative recovery and morbidity, resection can be carried out safely for both primary and recurrent cystic lesions no recurrence. Fenestration procedures provided adequate treatment with a quicker post-operative recovery but also a trend towards a higher recurrence rate, especially when carried out by laparoscopy.
91 Peripheral Cholangiocarcinoma in Mexico Ricardo Mondragon-Sanchez, Eduardo Hernandez-Castillo, Instituto Nacional de Cancerologia, Metepec, Mexico Introduction: Peripheral Cholangiocarcinoma (PCC)is an extremely rare tumor. In Mexico, it represents about 1.5% of all malignancies. It affects primarily male adults in the fifth decade of life. The most common symptoms are pain and weight loss, together with a palpable abdominal mass at physical examination. The treatment is usually difficult, being hepatic resection the most viable choice for the physician. The prognosis is still poor, with an overall survival of 5% at 5 years of follow up. We present here a series of PCC in a Cancer center at Mexico city. Patients and methods: We reviewed the clinical files in the Instituto Nacional de CancerologÌa at Mexico city of patients with the diagnosis of Peripheral Cholangiocarcinoma during the period of June 1992 to June 2002. Results: 11 patients were diagnosed with Peripheral Cholangiocarcinoma, 3 of them were male (28%), the other 8 were female (72%). The mean age at the time of diagnosis was 61 years (range 39-87). The most common symptoms were abdominal pain (81%), weight loss (63%), nausea and vomiting (27%). Abdominal mass was found in 6 patients (54%) and jaundice was reported in only one patient (9%). ACE was high in 6 out of 8 (75%) patients evaluated (mean: 104.6 ng/dl, range: 2.4150 ng/dl). CA19-9 was also measured in 8 patients, 7 (87.5%) of which were reported with elevated values (mean: 45,922.5 ng/dl, range: 150-146,440 ng/dl). All patients were submitted to surgery; left hepatectomy was performed in 4 of them (36.36%), right hepatectomy, left trisegmentectomy and right trisegmentectomy in 1 patient (9.09%). 4 patients could not be resected (36.36%) due to disseminated disease. 3 patients (27.27%) were initially proposed for intrarterial chemotherapy, because of non-resectable lesions, one of them was further submitted to surgical resection; the other two presented tumor succession. Only one patients was in for palliative radiotherapy. Post chirurgical complications were reported in 5 patients (45%). 2 patients died as a result of these complications. Conclusions: Peripheral Cholangiocarcinomas are even less frequent than their perihiliar counterpart. In Mexico, PCC occurs regularly in females. Hepatic resection is the only curative treatment available to date.
92 Resection of Non-Colorectal Liver Metastases Ricardo Mondragon-Sanchez, Elvira Gomez-Gomez, Eduardo HernandezCastillo, Instituto Nacional de Cancerologia, Metepec, Mexico Background: The liver is a common site of metastases in the spread of tumors. Hepatic resection in patients with colorectal metastases has been accepted as a therapeutic option. In contrast, treatment in patients with non-colorectal liver metastases is poorly documented in the world. Aims: To analyze results of hepatic resection in patients with non-colorectal liver metastases. Methodology: A retrospective analysis was performed with the database of patients with hepatic metastases from non colorectal origin that were resected from October 1995 to September 2002 in the Instituto Nacional de Cancerología. Results: From 150 hepatic resections performed, 34 were from non-colorectal liver metastases in 33 patients. 20 were females and 13 males with age from 15 to 70 years (mean: 39 years). The primary tumor originated from the breast in 7, testicular in 5, ovarian in 4, stomach in 4 and carcinoid tumors in 3, from melanoma, kidney and sarcomas in 2 and 4 miscellaneous. 17 patients presented symptoms (palpable mass, pain, weigh loss, jaundice). In 3 cases (10%) liver resection was performed at the time of the resection of the primary lesion. The mean tumor size was 6.8 cm (range from 2.3 to 30 cm). Nine right hepatectomies were performed, left hepatectomies (9), right trisegmentegtomies (6), non anatomic resection (3), left lateral segmentectomies (5), caudate lobe resection (1), resection of segment VII (1) and resection of segment II (1). Median operative bleeding was 1560 mL (range: 100-4000mL). Mean surgical time was 256 min (range: 120-390 min). Eight patients presented complications (23.5%): hepatic failure in 3, hemorrhage in 2, ascites, biloma and pleural effusion in one. There was one perioperative death (2.9%). Nineteen patients are still alive at a median follow up of 22 months (range 1 to 65). Conclusions: The presence of a low morbidity and mortality in this group of patients justify the option of treatment in selected patients with non colorectal liver metastases. The survival rate obtained in this series is similar of that obtained in colorectal liver metastases.
93
WITHDRAWN
nodal positivity, synchronous versus metachronous presentation, and extent of hepatic resection (lobectomy or greater resection versus lesser R/As). Conclusion: Hepatic control by R/A is adversely affected by increasing number of lesions and procedures required to clear disease.
Abstracts
285
non-simultaneous HBAL. Each BAL treatment lasted 6 hours. The common state of the patients and the biochemical indexes were studied. Results: After treated with bioartificial liver, ammonia, prothrombin time and total bilirubin index showed significant decrease. 2 days later, only ammonia still showed significance. In one month period, 1 case (1/7) in simultaneous group died while in non-simultaneous group 2 cases (2/5) died. Significance was shown in two groups. The total mortality rate was 25%. Conclusions: The constructed bioartificial liver can support liver functions in acute liver failure. The simultaneous HBAL is better than non-simultaneous HBAL.
89 Focal Adhesion Kinase Signaling in Hepatic Regeneration Carol P Bowen, Reid B Adams, University of Virginia Health System, Charlottesville, VA
87 Laparoscopic Management of Benign Hepatic Cysts and Cystic Neoplasms Robert E Glasgow, Michael D Rollins, Sean J Mulvihill, University of Utah, Salt Lake City, UT Benign cystic lesions of the liver include a wide spectrum of disease processes, including benign simple cysts, polycystic disease, and cystic neoplasms. The purpose of this video presentation is to illustrate the laparoscopic approach to benign cystic lesions of the liver. In this presentation, the laparoscopic treatment of a simple hepatic cyst, fenestration of polycystic liver disease, and excision of a giant hepatic mucinous cystadenoma will be demonstrated. Principles of laparoscopic treatment of benign cystic lesions include adequate preoperative imaging and the routine use of intraoperative laparoscopic ultrasound. We routinely use three to four trocars and a 30 or 45 degree laparoscope. Cyst and hepatic parenchymal division is performed with the Harmonic scalpel and electrocautery. For simple hepatic cysts, the cyst wall is excised such that at least 50% of the diameter of the cyst is unroofed. For cysts with a large intrahepatic component, the omentum is mobilized and placed within the cyst to facilitate closure. For polycystic liver disease, cysts are unroofed, resected, and/or fenestrated. If biliary communication is identified, the involved duct is suture ligated from within the cyst cavity. For cystic neoplasm, laparoscopic enucleation and resection are performed. Intraoperative frozen section evaluation of the cyst wall for malignancy is necessary. The postoperative course is similar to that for laparoscopic cholecystectomy. In summary, benign hepatic cysts and cystic neoplasms are effectively treated with a laparoscopic approach.
LIVER Other 88 The Development of a New Bioartificial Liver and its Application in 12 Acute Liver Failure Patients Yitao Ding, The Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing, China Background: Bioartificial liver is a hope of supporting liver functions in acute liver failure patients. Using polysulfon fibers, a new bioartificial liver was developed. The aim of this study was to show whether this bioartificial liver could support liver functions or not. Material and methods: Hepatocytes were procured from swine using Seglen’s methods. The bioartificial liver was constructed by polysulfon bioreactor and more than 1010 hepatocytes. It was applied 14 times in 12 patients, who were divided into 7 cases of simultaneous HBAL and 5 cases of
Introduction: The liver has considerable ability to regenerate in response to injury of many types. Following partial hepatectomy (PH), a rapid and specific series of biochemical events occur prior to cellular proliferation. Maximum DNA synthesis occurs within 24 hours of PH and regeneration is completed by 10 days. Post resection c-Jun, c-fos and liver regenerating factor-1 (LRF-1) mRNA levels are elevated within 30 minutes of the procedure. One critical regulator of cellular proliferation is adhesion mediated signals. These are regulated by focal adhesion kinase (FAK) following its activation by the interaction of integrins with the extracellular matrix. Yet the role of FAK and other adhesion signal mediators are unknown in liver regeneration (LR). Activated FAK results in increased cell motility, proliferation and suppresses apoptosis, all important in organ regeneration. We hypothesized that FAK would play a pivotal role in LR as evidenced by elevated protein levels and activation following resection. Method: Balb/C mice were divided into four treatment groups. (1): 24 hours after sham PH (n6), (2): 1 hour after 1/3 PH (n6), (3): 24 hours after 1/3 PH (n6) and (4): 288 hours after 1/3 PH (n2). All animals had a general anesthetic, a midline laporatomy and procedure noted above performed. At the study time indicated, the remainder of the liver was removed. A second group of animals underwent 1/3 PH, then at 1, 5, 10, 15, 30, and 60 minutes later, the remaining liver was resected. Liver cell lysates were analyzed by immunoblotting for FAK expression and activation. Results: FAK (total and activated) is downregulated in the post resected samples as compared to pre resection at 1 hr, 24 hrs and 288 hours. As this was unexpected, we analyzed the FAK family protein PYK2, and found its expression inverse to that of FAK. Activated FAK is increased very early after PH (maximum at 5-10 min), and then returned to baseline, whereas PYK2 stayed elevated until 30 minutes post resection and decreased to normal by 60 minutes. Downstream effectors of adhesion signaling also were activated early. Conclusion: LR stimulates changes in adhesion mediated signals, suggesting their involvement in hepatic growth. Regulation is early, within minutes, with FAK transiently increasing before being suppressed, whereas its related family member, PYK2 is upregulated for a more sustained time after PH. Further studies are warranted to elucidate the role of adhesion signaling in LR and hepatocellular carcinogenesis.
90 Resection for Symptomatic Hepatic Cysts: Is It Worthwhile? Yu-Meng Tan, London Lucien Ooi, Alexander Y Chung, Chow K Pierce, Lay Wai Khin, Singapore General Hospital, Singapore, Singapore; National Medical Research Council, Singapore, Singapore Background: Symptomatic liver cysts can be managed surgically by fenestration or by hepatic resection. Although fenestration procedures are preferred, this is associated with a higher recurrence rate. Conversely, hepatic resections are rarely associated with recurrence and are becoming a safer procedure in specialised units. Methods: 40
286
Journal of Gastrointestinal Surgery
Abstracts
patients with symptomatic liver cyst (non-parasitic and non-malignant) surgically treated by fenestration or resection were identified from a prospectively collected database. A retrospective analysis of primary outcome measures including operative parameters, morbidity and mortality rates, length of post-operative stay and recurrence rates in months was carried out to determine the better treatment option. Results: 27 patients had undergone fenestration (17 by open method and 10 by laparoscopic method) and 13 patients had undergone resection for treatment. Cyst and patient parameters were comparable in all three treatment arms. There was no mortality in our series. Morbidity was less in the fenestration group but in the resection group morbidity was mainly for minor complications like wound infection, chest infection and paralytic ileus. At median follow-up of 20 months, there were no recurrences in the resection group but 6/27 (22%) in the fenestration groups (3 in laparoscopic and 3 in open fenestration). Two required a hepatic resection and the other four were observed as they were asymptomatic radiological recurrences. Conclusion: The best result for our patients was obtained with resection. Although it was associated with a longer post-operative recovery and morbidity, resection can be carried out safely for both primary and recurrent cystic lesions no recurrence. Fenestration procedures provided adequate treatment with a quicker post-operative recovery but also a trend towards a higher recurrence rate, especially when carried out by laparoscopy.
91 Peripheral Cholangiocarcinoma in Mexico Ricardo Mondragon-Sanchez, Eduardo Hernandez-Castillo, Instituto Nacional de Cancerologia, Metepec, Mexico Introduction: Peripheral Cholangiocarcinoma (PCC)is an extremely rare tumor. In Mexico, it represents about 1.5% of all malignancies. It affects primarily male adults in the fifth decade of life. The most common symptoms are pain and weight loss, together with a palpable abdominal mass at physical examination. The treatment is usually difficult, being hepatic resection the most viable choice for the physician. The prognosis is still poor, with an overall survival of 5% at 5 years of follow up. We present here a series of PCC in a Cancer center at Mexico city. Patients and methods: We reviewed the clinical files in the Instituto Nacional de CancerologÌa at Mexico city of patients with the diagnosis of Peripheral Cholangiocarcinoma during the period of June 1992 to June 2002. Results: 11 patients were diagnosed with Peripheral Cholangiocarcinoma, 3 of them were male (28%), the other 8 were female (72%). The mean age at the time of diagnosis was 61 years (range 39-87). The most common symptoms were abdominal pain (81%), weight loss (63%), nausea and vomiting (27%). Abdominal mass was found in 6 patients (54%) and jaundice was reported in only one patient (9%). ACE was high in 6 out of 8 (75%) patients evaluated (mean: 104.6 ng/dl, range: 2.4150 ng/dl). CA19-9 was also measured in 8 patients, 7 (87.5%) of which were reported with elevated values (mean: 45,922.5 ng/dl, range: 150-146,440 ng/dl). All patients were submitted to surgery; left hepatectomy was performed in 4 of them (36.36%), right hepatectomy, left trisegmentectomy and right trisegmentectomy in 1 patient (9.09%). 4 patients could not be resected (36.36%) due to disseminated disease. 3 patients (27.27%) were initially proposed for intrarterial chemotherapy, because of non-resectable lesions, one of them was further submitted to surgical resection; the other two presented tumor succession. Only one patients was in for palliative radiotherapy. Post chirurgical complications were reported in 5 patients (45%). 2 patients died as a result of these complications. Conclusions: Peripheral Cholangiocarcinomas are even less frequent than their perihiliar counterpart. In Mexico, PCC occurs regularly in females. Hepatic resection is the only curative treatment available to date.
92 Resection of Non-Colorectal Liver Metastases Ricardo Mondragon-Sanchez, Elvira Gomez-Gomez, Eduardo HernandezCastillo, Instituto Nacional de Cancerologia, Metepec, Mexico Background: The liver is a common site of metastases in the spread of tumors. Hepatic resection in patients with colorectal metastases has been accepted as a therapeutic option. In contrast, treatment in patients with non-colorectal liver metastases is poorly documented in the world. Aims: To analyze results of hepatic resection in patients with non-colorectal liver metastases. Methodology: A retrospective analysis was performed with the database of patients with hepatic metastases from non colorectal origin that were resected from October 1995 to September 2002 in the Instituto Nacional de Cancerología. Results: From 150 hepatic resections performed, 34 were from non-colorectal liver metastases in 33 patients. 20 were females and 13 males with age from 15 to 70 years (mean: 39 years). The primary tumor originated from the breast in 7, testicular in 5, ovarian in 4, stomach in 4 and carcinoid tumors in 3, from melanoma, kidney and sarcomas in 2 and 4 miscellaneous. 17 patients presented symptoms (palpable mass, pain, weigh loss, jaundice). In 3 cases (10%) liver resection was performed at the time of the resection of the primary lesion. The mean tumor size was 6.8 cm (range from 2.3 to 30 cm). Nine right hepatectomies were performed, left hepatectomies (9), right trisegmentegtomies (6), non anatomic resection (3), left lateral segmentectomies (5), caudate lobe resection (1), resection of segment VII (1) and resection of segment II (1). Median operative bleeding was 1560 mL (range: 100-4000mL). Mean surgical time was 256 min (range: 120-390 min). Eight patients presented complications (23.5%): hepatic failure in 3, hemorrhage in 2, ascites, biloma and pleural effusion in one. There was one perioperative death (2.9%). Nineteen patients are still alive at a median follow up of 22 months (range 1 to 65). Conclusions: The presence of a low morbidity and mortality in this group of patients justify the option of treatment in selected patients with non colorectal liver metastases. The survival rate obtained in this series is similar of that obtained in colorectal liver metastases.
93
WITHDRAWN