Since the tumor thrombus in the main portal vein appears in the terminal stage of hepatocellular carcinoma (HCC), any attempt to remove it surgically is thought to be impractical as the malignancy itself cannot be entirely removed. During the past 5 years, we have performed tumor thrombectomy combined with hepatectomy in 29 of 298 patients with HCC. This combined therapy was initially decided upon as an emergency measure to prevent impending rupture of esophageal varices, rather than to improve patient survival. Since portal flow was obtained after removal of thrombi, this condition enabled transcatheter arterial embolization (TAE) and/or percutaneous ethanol injection therapy (PEIT). Although improved patient survival was not the primary goal of the emergency operation and there was an operative mortality of 11%, half of the other patients in the present series had unexpectedly high survival rates of 1 year (52.2%), 2 years (23.2%), and 3 years (11.6%), which were significantly higher than in patients not undergoing operation (n = 22).

Between January 1985 and July 1990, 323 cases of hepatocellular carcinoma underwent liver resection in our department. Bone metastases were found in 12 of these cases (3.7%). Bone metastases were mainly found in vertebral bone (58.3%) and pelvic bone (41.7%). The time interval to the development of bone metastasis after liver resection was closely related to the presence of intrahepatic metastasis and the stage at operation. In all cases, the initial clinical symptom was pain and/or motor disturbance. Radiotherapy was performed in 10 cases and transcatheter arterial embolization or surgery was performed in 4 cases. The pain or neurological symptoms improved with these therapies in all cases. Cumulative survival was 1 year in 74%, 2 years in 34%, and 3 years in 17%, respectively.

We report herein the case of a ruptured liver abscess that resulted in pneumoperitoneum. A patient with diabetes mellitus presented with symptoms of acute abdomen. The plain abdominal radiograph and computed tomography findings revealed abdominal free air and a gas-containing liver abscess, whereby a diagnosis of a ruptured liver abscess was made. An emergency operation was performed, and the abscess was drained followed by peritoneal lavage and the administration of appropriate antibiotics. To the best of our knowledge, very few cases of spontaneous pneumoperitoneum occurring secondary to the rupture of a gas-containing liver abscess have been encountered in Japan.

These results suggest that this new compartment analysis will be useful in evaluating liver function, as it is accurate, simple and convenient.

Ketogenesis was evaluated in 33 critically ill hepatectomized patients in relation to the arterial ketone body ratio (acetoacetate to 3-hydroxybutyrate), which reflects hepatic mitochondrial redox state. In 15 patients whose arterial ketone body ratio decreased to below 0.4, blood ketone body levels were significantly increased concomitant with marked increase of blood lactate and plasma alanine levels. In the 6 survivors of these 15 patients, the arterial ketone body ratio was restored within the next 2 days, and blood ketone body levels were decreased. By contrast, in the nine non-survivors, the arterial ketone body ratio remained below 0.4, and blood ketone body levels were decreased, accompanied by significant increases in blood lactate and plasma alanine levels in the terminal stages. These results suggest that ketogenesis acts as an alternative process for ATP synthesis in the liver in critically ill patients. Death occurs when the liver falls into an energy crisis concomitant with the cessation of ketogenesis.