The expression of vascular adhesion molecules and neutrophil adherence were investigated in the liver to evaluate the adverse effects of a temporary interruption of the hepatic inflow (Pringle's maneuver) during hepatectomy. In liver tissue specimens obtained from 16 patients (10 with liver cirrhosis (LC) and 6 without LC), immunohistochemical staining was used to detect the expression of granular membrane protein-140 (GMP-140), endothelial leukocyte adhesion molecule-1 (ELAM-1), and vascular cell adhesion molecule-1 (VCAM-1) by the hepatic vascular endothelium. In addition, neutrophil elastase was immunostained. After hepatectomy, the expressions of GMP-140 and VACM-1 were significantly higher in patients with LC than in those without LC. There was weak expression of ELAM-1 in the cirrhotic liver which was observed in 2 cases, but no expression in the non-cirrhotic liver. The adherent neutrohil count in liver tissue after hepatectomy was significantly higher in LC patients than that before hepatectomy as well as than that of non-LC patients. In conclusion, Pringle's maneuver enhances the hepatic neutrophil adhesion by upregulating the expression of endothelial adhesion molecules during an early period after hepatectomy, which may cause damage to the remnant liver in LC patients.
Objective: To observe pulmonary edema resulting from intestinal ischemia-reperfusion injury. We used a newly developed laser confocal microscope to observe the subpleural capillary network and the superficial alveoli under intravital conditions, and created three-dimensional images of the pulmonary microcirculation to analyze the time course and spatial pattern of pulmonary exudative changes during intestinal ischemia-reperfusion injury in vivo. Design: Prospective, randomized, unblinded study. Setting: Laboratory of a university hospital. Subjects: Male Sprague-Dawley rats. Interventions: The rats were injected intravenously with bovine serum albumin labeled with fluorescein isothiocyanate and subjected to 60 mins of intestinal ischemia, followed by 180 mins of reperfusion. During mechanical ventilation, the upper lobe of the right lung was examined in the intravital state using a high-speed confocal fluorescence microscope. Measurements and Main Results: Interstitial edema and alveolar leakage were recognized as changes of interstitial fluorescence in the subpleural capillary network and as changes of alveolar fluorescence in the alveolar cross-sectional view. Although exudative changes in the interstitium and alveoli were observed during intestinal ischemia, there was a marked increase in both interstitial edema and alveolar leakage after intestinal reperfusion. Conclusion: We observed pulmonary edema under intravital conditions and demonstrated the utility of a newly developed laser confocal microscope. This system not only enabled us to analyze the development of pulmonary edema three-dimensionally, but also allowed us to evaluate the pulmonary microcirculation.
Hepatopancreatoduodenectomy (HPD) with hepatectomy has been widely employed for advanced biliary tract carcinomas. In this paper 10 patients with biliary tract carcinoma undergoing HPD with hepatectomy were compared with control groups for operative stress, hepatic regeneration, and postoperative complications. These 10 patients were divided into 2 groups, namely 6 undergoing resection of more than 2 segments and 4, less than 2 segments. Another each 10 patients undergoing extended hepatectomy or HPD were severed as control. HPD patients with hepatectomy of more than 2 segments showed significantly greater values in operative bleeding amount, operating time, and postoperative complications than those of other 3 groups. Postoperative total serum bilirubin significantly increased in HPD with hepatectomy (more than 2 segments) group. There were no differences in restoration of remnant hepatic volume after extended hepatic lobectomy with or without pancreatoduodenectomy. Median survival after HPD was 12 months. According to a questionnaire survey reported at the 16th Japan Pancreatectomy Society, the commonest cause of hospital deaths in HPD patients was hepatic failure, followed by preoperative T. Bil. level of 3mg/dl or more, age of over 60, hepatectomy of more than 2 segments, and association of vascular reconstruction, in this order (with significant difference). It is thought that an increase in total bilirubin well expresses a significantly severe operative stress with HPD than that with usual hepatectomy. Accordingly, HPD can escape associating with postoperative hepatic failure and other complications by an appropriate selection of operative candidates preceded by sufficient reduction of serum bilirubin; careful vascular reconstruction; and good nutritional management.
Necrosis of small intestine and gastric mucosa in various clinical states is probably related to local mucosal hypoxia. These experiments, in which oxygen‐carrying perfluorochemicals were used to deliver oxygen directly into the lumen of ischaemic gut or stressed stomach, by reducing the rate of necrosis of intestinal villi and the rate of stress ulceration respectively, suggest that such methods may be useful in clinical situations.
A case of Jejunogastric intussusception (JGI) after gastrectomy is presented. A 72-year-old woman was admitted to the hospital because of sudden epigastric pain and vomiting followed by hematemesis. There was a history of undergoing a gastric resection (Billroth II) for a gastric cancer 17 years before. Endoscopic examination revealed that a large reddish-blue intesitne loop filled the lumen of the residual stomach. Abdominal CT also revealed a mass with ringed structure in the gastric remnant and jejunum. Based on the diagnosis of JGI, an emergency laparotomy was performed 24 hours after the onset of the symptoms. At operation, the efferent jejunal loop was found to be intussuscepted retrogradely through the entero-enterostomy and then via the afferent loop into the gastric remnant. After manual disinvagination, a part of gangrenous jejunal intussuscepiens was resected and gastro-jejunostomy was performed with Roux-en Y-type reconstruction. The postoperative course was uneventful and the patient was discharged on 26th hospital day. In a review of the Japanese literature, anather 28 cases of JGI are seen. These 29 cases including our case are characterized by: 1) that Billroth II method was employed in the initial operation in all cases; 2) most cases had a retrograde intussusception of the efferent jejunal loop; 3) the disease suddenly developed after a long-term interval after the initial operation; 4) the diagnosis was easily made by endoscopy, X-ray examination of the stomach, abdominal CT and abdominal ultrasonography; and 5) the prognosis was relatively good by appropriate treatment.
