The prediction of portal pressure: a multivariate analysis of clinical data and intraoperative portal pressure

Portal pressures were estimated non-invasively in 100 patients who underwent hepatic resection and completely fulfilled the 21 variables evaluated. Ten variables were selected from among all those in the univariate analysis, and a stepwise discriminant analysis revealed four independent significant variables, namely: The indocyanine green dye retention test at 15 min (ICGR15); the prothrombin time index; the platelet count; and the globulin fraction. An equation to estimate the portal pressure was made using the coefficients in the analysis, the reliability of which was confirmed (r = 0.70484, P = 0.0001). The univariate analysis revealed ten significant variables to discriminate portal hypertension, defined as a portal pressure of over 200 mmH2O. A multiple logistic regression analysis of these variables revealed two independent variables, being ICGR15 and the platelet count. Thus, we consider that our equation for estimating portal pressure is potentially useful, and that the platelet count and ICGR15 are the most significant parameters in discriminating between the presence or absence of portal hypertension. Moreover, a platelet count of less than 120 x 10(3)/mm3 and an ICGR15 value of more than 15% correlated well with portal hypertension.


Changes in regulating blood coagulation in hepatic resection with special references to soluble thrombomodulin and protein C

The protein C anticoagulant pathway in hepatic resection was studied. The patients were divided into two groups--group 1 consisted of patients with a normal liver and group 2 consisted of patients with either hepatitic or a cirrhotic liver. Plasma protein C activity and soluble thrombomodulin were then sequentially measured during hepatectomy and in the early postoperative period. The protein C activity in group 1 decreased during hepatectomy and reached a low immediately after operation, and thereafter, recovered to near preoperative levels. However, the preoperative value in group 2 was lower than that in group 1 and the postoperative values were significantly lower than those in group 1 (p < 0.05). The level of soluble thrombomodulin in group 1 decreased during hepatectomy but later returned to preoperative levels. However, in group 2, the preoperative value was higher than that in group 1 and the postoperative values were greater than that of the preoperative values, while the values were significantly higher than those in group 1 (p < 0.05). During hepatectomy, hypercoagulability may contribute to the low levels of protein C and soluble thrombomodulin. The postoperative significant increase of soluble thrombomodulin may, thus, indicate the occurrence of endothelial injury in the remnant liver. The sequential measurements of both parameters can, therefore, be useful in detecting coagulopathy and endothelial injury in hepatic resection.


Strategies for reducing blood transfusions in hepatic resection

A comparison of 60 blood transfused and 71 nonblood transfused hepatic resection patients was done to evaluate strategies for reducing blood transfusions during hepatic surgery. There were no significant differences between the two groups with regard to preoperative laboratory data, except for prothrombin time and hematocrit value. The mean operative blood loss was 1990 ml and 760 ml in the blood transfused and nonblood transfused groups, respectively. A multivariate analysis suggested that the patient's body weight, preoperative prothrombin time, and operative blood loss independently predicted the need for intraoperative blood transfusion. Major postoperative complications developed more frequently in the blood transfused group than in the nonblood transfused group (31.7 vs. 11.3%, p < 0.005). These results suggest that the difference in operative blood loss between the two groups was related to the prolonged prothrombin time and a susceptibility for blood transfusion was found to exist particularly in patients with a lower hematocrit value as well as a lower body weight. Thus, the improvement of these preoperative laboratory data combined with avoiding the use of the hematocrit value as a determining factor for intraoperative transfusion could correspond to a reduction in operative blood loss, while curtailing the demands on blood bank facilities, and lowering the risk of postoperative complications.


The effects of pirenzepine and famotidine on hepatic resection. a randomized prospective study


Open and closed suction drainage after hepatic resection


The significance of methicillin-resistant Staphylococcus aureus infection in general surgery: a multivariate analysis of risk factors and preventive approaches


Extracorporeal hepatic resection for previously unresectable neoplasms


Effect of diabetes mellitus on hepatic resection


Alternate hemihepatic vascular control technique for hepatic resection

This report describes a simple and improved inflow control technique for resection of a hepatic tumor that lies across the right and left hepatic lobes. With alternate hemihepatic inflow control by en masse occlusion of Glisson's sheath of each hemipedicle at the bifurcation, hepatic resection across the two hepatic lobes is completed. Compared with Pringle's maneuver, this technique eliminates splanchnic congestion and reduces warm ischemia of the remnant liver, while maintaining a comparable hemostatic effect.


Liver resection and intractable postoperative ascites

Among 211 patients who, between 1985 and 1990, underwent liver resection in Kyushu University Hospital, uncontrollable ascites occurred in 53 (25%). A univariate analysis revealed that postoperative death with liver failure occurred more frequently in patients with intractable ascites (p < 0.05). Alanine amino transferase levels were significantly higher in patients with intractable ascites (p < 0.05), but serum bilirubin, alkaline phosphatase and serum albumin levels did not differ significantly. Portal pressure (p < 0.05), the operation time (p < 0.01) and blood loss (p < 0.01) were significantly higher in patients with intractable postoperative ascites. A multiple analysis showed a correlation between the operation time, portal hypertension and postoperative intractable ascites. Postoperative histology revealed that a larger number of patients with cirrhosis had intractable ascites (p < 0.05). We conclude that cirrhosis, portal pressure and operating time are the most important factors related to intractable ascites in the case of hepatectomy. Areas of the liver to be resected should be limited in cirrhotic patients with portal hypertension.


A safe and simple technique for exchanging central venous catheters


外科領域感染症に対するempiric therapyにおけるFMOXの有用性の検討


Prediction of survival of patients with esophageal varices treated by endoscopic injection sclerotherapy in Japan


肝切除術における血液凝固線容系の変動

肝切除術における血液凝固線容系の変動


Pretransplant assessment of human liver grafts by plasma lecithin: cholesterol acyltransferase (LCAT) activity in multiple organ donors

In spite of the improved outcome of orthotopic liver transplantation (OLTx), primary graft nonfunction remains one of the life-threatening problems following OLTx. The purpose of this study was to evaluate plasma lecithin: cholesterol acyltransferase (LCAT) activity in multiple organ donors as a predictor of liver allograft viability prior to OLTx. Thirty-nine donors were studied during a 5-month period between April and August 1988. Allograft hepatectomy was performed using a rapid technique or its minor modification with hilar dissections, and the allografts were stored cold (4 degrees C) in University of Wisconsin (UW) solution. Early post-transplant allograft function was classified as good, fair, or poor, according to the highest SGOT, SGPT, and prothrombin time within 5 days following OLTx. Procurement records were reviewed to identify donor data, which included conventional liver function tests, duration of hospital stay, history of cardiac arrest, and graft ischemic time. Blood samples from the donors were drawn immediately prior to aortic crossclamp, and from these plasma LCAT activity was determined. Plasma LCAT activity of all donors was significantly lower than that of healthy controls (12.4 +/- 8.0 vs 39.2 +/- 13.3 micrograms/ml per hour, P less than 0.01). LCAT activity (16.4 +/- 8.3 micrograms/ml per hour) in donors of grafts with good function was significantly higher than that in those with fair (8.6 +/- 4.5 micrograms/ml per hour, P less than 0.01) or poor (7.3 +/- 2.4 micrograms/ml per hour, P less than 0.01) function.(ABSTRACT TRUNCATED AT 250 WORDS)


イヌの肝移植実験と問題点

イヌの肝移植実験と問題点


尾状葉原発肝細胞癌切除術の問題点

尾状葉原発肝細胞癌切除術の問題点


Flow-waveform controlled pulsatile perfusion for liver preservation


Viability of porcine transplanted liver graft determinable by serum lecithin:cholesterol acyltransferase (LCAT) activity


Pancreatic complications following orthotopic liver transplantation


Interactive statistical analysis system for clinical investigators

We have developed an interactive statistical analysis system (ISAS-Q) with which clinical investigators with little experience in computers and programming can easily perform statistical analyses. ISAS-Q can perform most of the frequently used statistical methods, including multivariate analysis, in an interactive mode. Furthermore, ISAS-Q has self-consistent and extensive help functions.


A random allocation system with the minimization method for multi-institutional clinical trials

This paper describes the random allocation system used to perform precise and rapid treatment assignments in multi-institutional clinical trials. This system is based on sophisticated randomization procedures, according to Pocock and Simon's minimization method and Zelen's method for institution balancing. The major advantage of randomized treatment assignments with this system is to balance treatment numbers for each level of various prognostic factors over the entire trial and at the same time balance the allocation of treatments within an institution. Therefore, the randomized treatment assignments by this system can prevent degrading of the statistical power of a particular treatment factor. This system is designed to run on a small-sized notebook computer and therefore can be set up beside a telephone for registration, without occupying a large space. At present, this system is conveniently being used in two clinical trials.


Simulation program for estimating statistical power of Cox's proportional hazards model assuming no specific distribution for the survival time


A 24-hour ordering system for clinical examinations

We have developed a 24-hour ordering system for clinical examinations, making use of the features of multi-function workstation (IBM5550) which performs two functions both in an on-line terminal and in a personal computer. It is used as an on-line terminal for the host computer (IBM4381) in day time. At night or on holiday, it is used as a stand-alone type personal computer to order clinical examinations. For this purpose, basic information of the inpatients (patient number, name, sex, date of birth, clinic, ward) are transferred from the host computer to the disket in the workstation in the evening when host computer finished on-line service. A physician can input the patient number followed by examination items using the touch panel according to the dialogue type guides written in Chinese character. Then, specimen label, list of ordered tests and an order form are printed out instantly. The date (patient number, examination items, identification number of the specimen, etc.) stored in the disket in the workstation at night are transferred from workstation to the host computer next morning. The host computer merges the information ordered in day time and at night and supplies working documents for examination (worksheets, master log, etc.) to technicians. Thus physicians can order examinations all day long using workstation, which make it possible to spare the time.


A personal computer network system for equitable allocation of cadaver organs

We developed a personal computer network system for the equitable allocation of cadaveric organs. This network consists of a host computer (IBM PS55 model 5570 T) and various kinds of personal computers manufactured by many different computer makers in Japan. The merits of our personal computer network include lower cost and an easy access to the host computer from all the centres participating in this network while using their own favourite personal computers. Among the programs made for allocating cadaveric organs, we present in this paper the program for livers. This program was developed with a modified version of the logic developed by Starzl et al. The grade modification for the United Network for Organ Sharing (UNOS) in the United States was used as the basis for classification of medical urgency. Our program weighed the factors of medical urgency, compatibility of blood group and waiting time. Distance factors were omitted because of the smaller area of the network compared to that of UNOS. This computer network would be linked to other computer networks in creating a national organ procurement and transplant network in Japan, in order to help them to catch up with other advanced transplant countries. Such an equal and objective computer system should allow organ transplantation to become more widely accepted.


Micro-mainframe-like personal clinical research system


Ammonia elimination as a rapid index of viability in liver grafts in dogs


Improved method of porcine renal allografting for transplantation research

This study presents a refined, reproducible, and clinically appropriate animal model of renal transplantation. A pair of kidneys are harvested from a donor pig and preserved in Euro-Collins' solution (4 degrees C). After a set period of preservation, the allografts are transplanted to two recipient pigs. The abdomen is entered through a midline incision. The right common iliac artery and vein are dissected and bilateral native nephrectomy is performed. Each allograft is then randomly assigned and transplanted to the recipients. Three minutes before unclamping, 100 mg of furosemide and 10 g of mannitol are given IV. Immediately after reperfusion, urine output is measured for 1 h. The allograft is biopsied and ureteroneocystostomy is created. Cystostomy is then placed using a 16F Foley catheter. The bladder neck is ligated to secure complete diversion of urine, and the abdomen is closed in layers. This kidney transplant model allows an absolutely paired study of the kidney allograft function from the same donor and also collection of pure urine at any time postoperatively, obviating the need for metabolic cages or sedation for urinary collection. This model and its unique modifications allow various transplant studies, including organ preservation, immunosuppressive protocol, and the prevention of reperfusion injury from oxygen free radicals.


A simple and reliable assessment of liver allograft quality by analysis of effluent flushed from the grafts before liver transplantation in dogs


A disposable patient identification card made of a paper

This paper describes a patient identification system with a disposable paper card. In general, total costs of cards themselves, equipments and personnel are remarkable, not negligible for the hospital management. Therefore, a disposable identification cards made of a paper were issued to out-patients in our hospital. Many order forms were integrated into only one sheet. Patient identification data were printed on this sheet by a computer system when a patient came to the reception desk, and quickly transmitted to physicians. We could save the hospital costs and printing works by physicians, and also shorten the waiting time of patients at reception desks.


Development of an automatic medical summary report system

We developed a medical summary report system. In this system, each department can specify the predetermined conditions for issuing the summary report. The summary is made through a hierarchical database in the integrated hospital information system according to the predetermined conditions. The summary automatically issued after reception of the outpatient, or also issued by on-line summary report program with the patient number if requested by doctors. The report is sent to the proper consulting room from the reception desk using an air-shooter. The report contains the patient information such as a patient name, age, sex, birthday, a clinic name, a chart number, a patient number, diagnoses and examinations. The doctors can refer to the points of the clinical history of the patient in his own and other departments, and make a correct diagnoses and avoid the overlaps of the examinations and medications. This system has contributed to the quality-up of the patient care by availability of patient information even in other departments without the medical chart.


Plasma lecithin/cholesterol acyltransferase (LCAT) activity in multiple-organ donors: a predictor of allograft viability in clinical liver transplantation


Ex vivo perfusion for accurate assessment of liver graft viability in dogs

A new type of ex vivo liver perfusion model (EVPM) was developed. The system includes a physiological porto-portal connection, using a centrifugal pump and an aorto-aortal connection, through a heparin-coated tube. Ten pairs of mongrel dogs, weighing 13-20 kg, were used. Grafts of the liver procured from donors were perfused on the EVPM for 3 h. These grafts were divided into two groups: group A (n = 5), nonpreserved graft; group B (n = 5), 8-h graft preserved with lactated Ringer's solution (4 degrees C). The orthotopic liver transplantation (OLTx) series with the nonpreserved graft was reviewed, and dogs surviving for over 7 days following OLTx, group C (n = 5), were selected for liver grafts in the actual OLTx. In comparison with groups A and C, no difference was noted among enzyme levels (sGOT, sGPT, LDH) or in the recovery rate of ATP content in the graft liver tissue after revascularization. There were significant differences between group A and group B after revascularization. This simple and physiological EVPM accurately reflects graft function and hemodynamics in the actual OLTx. Graft viability, as a substitute for OLTx, in large animals can be reliably assessed. This EVPM is expected to contribute to research on events related to liver transplantation.


A new liver perfusion and preservation system for transplantation research in large animals

A kidney perfusion machine, model MOX-100 (Waters Instruments, Ltd, Rochester, MN) was modified to allow continuous perfusion of the portal vein and pulsatile perfusion of the hepatic artery of the liver. Additional apparatus consists of a cooling system, a membrane oxygenator, a filter for foreign bodies, and bubble traps. This system not only allows hypothermic perfusion preservation of the liver graft, but furthermore enables investigation of ex vivo simulation of various circulatory circumstances in which physiological perfusion of the liver is studied. We have used this system to evaluate the viability of liver allografts preserved by cold storage. The liver was placed on the perfusion system and perfused with blood with a hematocrit of approximately 20%, and maintained at 37 degrees C for 3 h. The flows of the hepatic artery and portal vein were adjusted to 0.33 mL and 0.67 mL/g of liver tissue, respectively. Parameters of viability consisted of hourly bile output, oxygen consumption, liver enzymes, electrolytes, vascular resistance, and liver histology. This method of liver assessment in large animals will allow the objective evaluation of organ viability for transplantation and thereby improve the outcome of organ transplantation. Furthermore, this pump enables investigation into the pathophysiology of liver ischemia and preservation.


Reversal of hypersplenism following orthotopic liver transplantation


The effect of preservation fluid on the blood flow of pediatric liver allografts


Low dose 1-hexylcarbamoyl-5-fluorouracil (HCFU) recommended for cirrhotic patients with hepatocellular carcinoma

The metabolism of 1-hexylcarbamoyl-5-fluorouracil (HCFU), a drug prescribed for treating patients with hepatocellular carcinoma (HCC), was studied in relation to liver function, with the objective of clarifying the occurrence of any adverse side-effects on the central nervous system. Twenty-five HCC patients were administered 3.4 mg/kg HCFU once orally, after which the blood levels of HCFU and its derivatives (5-FU, CPEFU, CPRFU, HHCFU, OHCFU and F-beta-alanine) were serially measured using high performance liquid chromatography. The area under the concentration curve (AUC) of HCFU in the group of ICG R15 greater than or equal to 30% (group 2) was 5.35 +/- 1.73 h.micrograms/ml, a value which was significantly higher than the 2.60 +/- 1.19 h.micrograms/ml recorded for the group of ICG R15 less than 30% (group 1) (P less than 0.001). The AUC of HCFU had a significant positive correlation with the value of ICG R15 (P = 0.002) or the serum total bilirubin (P = 0.0005). The AUC of 5-FU showed no difference between the two groups. The AUC of CPRFU in group 2 was 0.16 +/- 0.25 h.micrograms/ml, a value significantly lower than the 0.48 +/- 0.39 h.micrograms/ml in group 1 (P = 0.023). There was no correlation between the AUC of other derivatives and the markers of liver function. These data suggest that, in patients with advanced cirrhosis, the accumulation of HCFU is related to the occurrence of side-effects from the administered drug, ingested over a long-term period. Therefore, when HCFU is given to cirrhotic patients with both HCC and 30% or more ICG R15, a careful monitoring for side-effects is required.


Significance of blood flow measurement in clinical liver transplantation


Long-term results of arterial reconstruction of lower extremities determined by flow waveform analysis

Arterial reconstructions of the lower extremities were reviewed to assess the usefulness of flow waveform analysis. Six hundred and thirty-four arterial reconstructions were divided into two groups: a former (1965-1973) group of 218 reconstructions not assessed by flow waveform analysis and a recent (1974-1985) group of 416 reconstructions analyzed according to flow waveform. The cumulative patency rates of the former and the recent group at 5 years were as follows: aorto-femoral, 75.2% and 86.7% (P less than 0.05); femoral-distal, 34.6% and 61.5% (P less than 0.001); extra-anatomical, 63.6% and 80.2% (P = 0.06), respectively. Based on the various flow waveforms evidenced intraoperatively, the cumulative patency rate of cases in the recent group with type 0 and I flow waveform was compared to the rate of those with type II flow waveform. The cumulative patency rates at 5 years were as follows: aorto-femoral, 92% and 82.7% (P = 0.15); femoral-distal, 77.7% and 49.3% (P less than 0.001); extra-anatomical, 91.8% and 68.9% (P less than 0.05), respectively. These results indicate that intraoperative flow waveform analysis is a simple and useful indicator for predicting the long-term results of arterial reconstruction.


Hepatic artery thrombosis following pediatric liver transplantation:assessment of blood flow measurement in allografts


腹部大動脈瘤術後合併症の検討-特に術前腎機能と術後合併症との関連について

腹部大動脈瘤術後合併症の検討-特に術前腎機能と術後合併症との関連について


移植自家静脈片内膜肥厚防止のための血流改善補助ポンプの 開発に関する研究

移植自家静脈片内膜肥厚防止のための血流改善補助ポンプの 開発に関する研究