Although septic shock is frequently developed in patients with acute respiratory distress syndrome (ARDS), why these two pathologic conditions are associated is not known at present. Prostacyclin plays important roles in prevention of pulmonary vascular injury and shock responses by inhibiting increases in lung tissue levels of tumor necrosis factor (TNF) in rats administered endotoxin. Neutorphil elastase has been shown to decrease the endothelial production of prostacyclin. We attempted to determine whether sivelestat, a neutrophil elastase inhibitor. reduce the pulmonary vascular injury and hypotension by inhibiting the decrease in the pulmonary endothelial production of prostacyclin in rats administered endotoxin. Animals were pretreated with a neutrophil elastase inhibitor, sivelestat, before endotoxin administration. Lung tissue levels of 6-keto-PGF1α were markedly increased after endotoxin administration, followed by the rapid decrease. Sivelestat inhibited these decreases and increases in both lung tissue levels of TNF and lung wet-to-dry weight ratio in animals administered endotoxin. Sivelestat also reduced hypotension and inhibited increases in lung tissue levels of mRNA of iNOS, iNOS activity, and those in plasma levels of NO2-/NO3- in animals administered endotoxin. These effects of sivelestat were completely reveresd by pretreatment with indomethacin, a non-specific cyclooxygenase inhibitor. These observations suggested that neutrophil elastase might decrease the pulmonary endothelial production of prostacyclin, thereby increasing lung tissue levels of TNF, contributing to the development of pulmonary vascular injury and shock in rats administered endotoxin. Thus, it is likely that the activated neutrophil-induced pulmonary endotherial cell dysfunction leading to decrease in prostacyclin is a common cause for development of both ARDS and septic shock. This notion might explain why ARDS and septic shock are frequently associated in the clinical setting.
To investigate whether the postoperative renal function in patients with renal cell carcinoma can be predicted by the preoperative serum creatinine (sCr) and the renal parenchymal volume (RPV) estimated by the preoperative 3-dimensional image reconstruction. Seventy-six and 26 patients who underwent radical and partial nephrectomy were subjected to this study. The postoperative RPVs were estimated from the preoperative CT or MRI, and were compared with the RPVs estimated from the postoperative imaging. The postoperative creatinine clearance (Ccr) was predicted by the preoperative Ccr calculated from the sCr level and by the ratio of the postoperative/preoperative RPV. The predicted postoperative Ccr significantly correlated with the actually measured postoperative Ccr. Prediction of the postoperative Ccr, using the preoperative sCr and the preoperative diagnostic imaging, is a simple and reliable method.
Eight male beagle dogs (12-24 months of age, 10-18 kg body weight) were used in this study. All dogs were castrated and then administered 5a-androstane-3α, 17β-diol (3α-diol) plus 17β-estradiol (estradiol) for 24 weeks according to Walsh and Wilson's method. Microwave needle ablation of the prostate using microwave tissue coagulator (MTC) was performed the dog when its prostate become over 25 mL in volume. At the experimental day, 1w, 4w, 12w, dogs were slaughtered and the prostate was harvested. Bladder and external sphincter samples demonstrated no gross abnormalities. Microwave needle ablation can ablates rapidly and constantly. The range which microwave reaches is always exact. The needle position and extend of ablating can be revealed with transrectal ultrasonography. We performed microwave needle ablation of the prostate using MTC to one BPH patient who got his consent. His episode of care was good. The immediate goal is to obtain the fundamental data, and to verify the clinical availability of microwave needle ablation for the treatment of BPH and localized prostate cancer.
Purpose : To characterize the effects of saline injection during microwave irradiation in fresh uterine myoma tissue. Material and methods : Microwaves were applied at 70 and 110 W for 5-20 minutes with non-coated needle electrodes 1.6mm in diameter for deep site coagulation. Saline was injected at 0.1-0.2 mL/min through Teflon sheath of an electrode into myoma tissue greater than 10 cm in diameter of fresh surgical specimen of the uterus. Results : Myoma tissue contracted during microwave irradiation. The contraction was inhibited by saline injection. Saline injection protected electrodes from tissue adhesion. Conclusions : Microwaves with saline injection can induce coagulation without tissue adhesion, which will likely benefit clinical ablation of large myomas. Further investigation is needed to evaluate the effects of saline injection on increasing coagulation.
From the experiences of multiple disseminated recurrence after radiofreqency ablation, we thought that an increase in intra-tumor pressure during the thermal therapy and maneuver at hepatic resection might induce the release of tumor cells. Not to scatter microvascular thrombus around the tumor, we've started to try, as a first step of MCN, to coagulate close to portal vein and drainage vein of the tumor. After this step, for suppressing the increase the intra-tumor pressure, MCN should be done from the outside of the tumor and the center of the tumor should be coagulated lastly.
Background/Aims : We examined whether fourdimensional real-time flow imaging on ultrasonography (US) is valuable to display the accurate position of percutaneous radiofrequency ablation (RFA) needle in the nodule of hepatocellular carcinoma (HCC). Methodology : Twenty-five patients with 28 HCC nodules were studied. Percutaneous RFA was performed with four-dimensional real-timeflowimaging under US to display the accurate position of cool-tip needle. Results : It was possible to obtain accurate position of needle during RFA procedure in all 28 nodules. The needle was confirmed to be inserted into the center of tumor nodule by various angles. Conclusions : It appeared that four-dimensional real-time US provided more perceptible information on the spatial relationship between RFA needle and the target lesion, and resulted in accurate therapeutic efficacy for percutaneous RFA procedure.
Microwave coagulation therapy (MCT) has been widely applied for hepatic malignant tumor as non-surgical resection modalities. Although MCT obtain satisfactory parenchyma coagulation and hemostasis, it is considered to be insufficient effect if the tumor was closed to main vessel due to cooling system by blood circulation. Cryotherapy is known to be used for achieve optimal margin clearance of the tumor. It is delivered with liquid nitrogen based compact system (CRY-AC, Brymill Co, USA). The inadequate resection margins after hepatectomy was ablated directly for 3 minutes per place generally, advantage of cryotherapy obtain less damage to vessels. We suggested that the use of combination of MCT and cryotherapy provide satisfactory hemostasis and optimal surgical margin after hepatectomy even if tumor was closed to main vessels.
Recently, laparoscopic hepatectomy has seen increasing as one of a minimal invasive therapy. We have performed laparoscopic surgery in 59 patients with liver tumors. In this report, we focus on a new device of microwave coagulator for laparoscopic hepatectomy. The characteristics of this device are smaller diameter (5 mm) and angle flexibility (maximum 45 degree). It can be used even in smaller working space compared with previous 10 mm device. We were able to performed laparoscopic hepatectomy for a patient with hepatocelular carcinoma and sever liver cirrhosis by using this new device safely.
A 72-year-old woman who underwent Mile's operation for rectal cancer (t2n1M0 stage III a) 6 months ago, was pointed out solitary liver tumor located just below top of the diaphragm and was successfully treated by thoracoscopic microwave coagulation therapy (MCT). We thought three devices out for getting radical coagulation necrosis of the tumor during the operation as follows ; 1) Diaphragm incision by a ultrasonically activated device to observe the tumor directly, 2) Moving tumor in gentle manner using small bended gauze, 3) Placing MCT antenna vertically into the tumor using flexible MCT device. In these manners, we could recognize the tumor to be coagulated completely during the operation and enhanced CT scan also revealed tumor necrosis with sufficient surgical margin.
Clinical application of laparoscopic hepatectomy for hepatocellular carcinoma depends on the development of surgical devices, especially in cirrhotic liver. However, there is no device suitable for all the situations as coagulation, skeltonization and division in liver transection. We have been introducing TissueLink monopolar sealer (TMS)/DS 3.0 which can provide excellent hemostasis in parenchymal transection through the small incision in laparoscope assisted left lateral segmentectomy. Partial hepatectomy for tumor located in the edge of lower segment can be performed using only TMS/endo (SH2.0) sealing hook. In tumorectomy located in the ventral surface of liver, the use of microwave tissue coagulator and laparoscopic coagulating shears is appropriate combination to obtain safe surgical margin and hemostasis. Important considerations for successful laparoscopic hepatectomy are the selection and the surgical skill of appropriate devices as well as the patient selection.
Since July 1994, we have used microwave coagulo-necrotic therapy (MCN) for patients with hepatocellular carcinoma (HCC) in our institute. All our new patients were classified by prognostic staging system (CLIP score, JIS score, modified JIS score and Tokyo Score) and those survival rate were assessed. In each staging score, the cumulative survival rates in MCN group were almost equal to those in hepatic resection (Hr) group. Based on the above, it was suggested that MCN has the ability of loco-regional control of HCC and MCN can be a first choice for the treatment of HCC.
We analyzed the survival rates, local recurrence rates, and another recurrence rates for patients with solitary hepatocellular carcinoma who received thermal ablation therapies as primary treatment (naive patients). In these 89 patients, 35 cases were ablated by percutaneous radiofrequency ablation (PRFA), 32 were treated by laparoscopic microwave coagulation (LMCT), and 22 were treated by percutaneous microwave coagulation (PMCT). 5-year survival rates were 87% in PRFA, 56% in LMCT, 76% in PMCT. The differences of survival rates were not statistically significant among PRFA, LMCT, and PMCT. 5-year local recurrence rates were 49%, 26%, and 44%, consecutively. No differences were found between therapies. 5-year another recurrence rates were 100%, 81%, and 80%, consecutively. No differences were found statistically.
Purpose : Radiofrequency ablation (RFA) therapy for hepatocellular carcinoma (HCC) has made good local control possible. In this study, the efficacy of RFA is evaluated and predictive factors for distant recurrence are identified. Methods : 135 patients with initial HCC were treated with combination of chemoembolization and real-time CT guided RFA. Results : Recurrence rates after initial RFA were 5% at 2 y for local, and 41.4% at 2 y for distant. In HCV patients, significantly high recurrence rates were observed in cases with initial multi-occurrence, low albumin levels, high AST levels and low platelet counts. However, on multivariate analysis, low albumin levels and high AST levels were independent predictive factors for cumulative distant recurrence after RFA. Conclusion : Although RFA enables good local control for initial HCC, distant recurrence is observed at high rates. Low albumin and high AST levels are predictive factors for distant recurrence.
Subjects were 981 cases of hepatocellular carcinomas (HCC). We divided these subjects into 12 categories according to TNM Stage (I, II, III, IV) and Liver damage (A, B, C). Then we compared the therapy rates of use and those survival rates in each category. The treatment outcome of ablation in Stage I was the same as hepatectomy. On the other hand, in the case of more than Stage II, treatment outcome of hepatectomy was better than those of the other therapies. As for these results, it was thought that it was important in future when we reviewed the algorithm of HCC treatment.
102 patients with solitary hepatocellular carcinoma (HCC) less than 3 cm in diameter were enrolled in this study. Among these patients, 77 patients were treated by percutaneous radiofrequency ablation (RFA), and the others were subjected to hepatic resection. The cumulative 1-, 2- and 3-year's recurrence rate in the RFA group was 20.5, 43.1 and 67.7 %, respectively, while 16.0, 33.3 and 53.6 % in the hepatic resection group. The cumulative 1-, 2-, 3- and 4-year's survival rate in the RFA group was 98.6, 96.2, 79.1 and 79.1 %, respectively, while 96.0, 96.0, 91.4 and 85.7 % in the hepatic resection group. Multivariate analysis showed no difference between these groups concerning both recurrence and survival after therapy. We believe that RFA is more desirable therapy for small HCC, because it is important to reserve hepatic function in patients with HCC in whom recurrence after therapy is frequent due to underlying liver disease.
A 72-year-old woman was admitted for suspected liver tumor. The abdominal CT showed a hepatocellular carcinoma (HCC) 4.5 cm in diameter in her cirrhotic liver, splenomegaly and large porto-systemic shunts in the periesophagogastric region. Fiberscopic examination revealed risky esophageal varix (EV), and the labolatory data showed pancytopenia of hypersplenism and poor liver function. We decided to perform a gastroesophageal decongestion and splenectomy (Hassab operation) for her EV, large porto-systemic shunts and hypersplenism before partial hepatectomy for the HCC. Although we performed Hassab operation successfully, she suffered from portal vein thrombus and ascitic fluid that could not be controlled by medication after the operation. We gave up the idea of hepatectomy, and performed radiofrequency ablation therapy for the HCC. She discharged from hospital uneventfully, and are alive now free from HCC.
Objective : The purpose of this study was to evaluate the efficacy and safety of radiofrequency ablation (RNA) in patients with hepatic metastases. Materials and Methods : Fourteen patients with a total of 21 hepatic metastases (1.0-5.0 cm in diameter) were treated with RFA. Results : There were no treatment-related deaths. Twenty of 21 treated tumor were completely necrotic on imaging studies. With a median follow-up of 31.4 months, tumor has recurred in 5 of these 20 treated lesions (25%). One of these tumors (2.0 cm in diameter) was located near the right hepatic vein, and other four were more than 3.5 cm in diameter. Conclusion : RFA is a safe and effective treatment to treat hepatic metastases.