Portal Application of Autologous CD133+ Bone Marrow Cells to the Liver: A Novel Concept to Support Hepatic Regeneration
http://www.100md.com
《干细胞学杂志》
a Departments of General Surgery,
b Cardiothoracic Surgery,
c Diagnostic Radiology,
d Hemostaseology and Transfusion Medicine, and
e Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine-University of Duesseldorf, Duesseldorf, Germany,
f Institute of Clinical Pharmacology, University of Witten/Herdecke, Witten, Germany
Key Words. Adult bone marrow stem cells ? Liver regeneration ? AC133 antigen ? Somatic cell therapy ? Clinical trials ? Clinical stem cell transplantation
Correspondence: Wolfram Trudo Knoefel, M.D., F.A.C.S., Department of General Surgery, Heinrich-Heine-University of Duesseldorf, Moorenstrasse 5, D-40225 Duesseldorf, Germany. Telephone: 49-211-8117350/51; Fax: 49-211-8117359; e-mail: knoefel@uni-duesseldorf.de
ABSTRACT
In up to 45% of patients with primary or secondary liver tumors, extended hepatectomy (greater than five segments) is necessary to achieve tumor-negative resection margins . However, patients with an anticipated future liver remnant volume (FLRV) below 20%–25% of total liver volume (TLV) have an increased incidence of postoperative morbidity and mortality . The concept of preoperative expansion of the left-lateral FLRV (segments II and III) using selective portal venous embolization (PVE) of contralateral liver segments I and IV to VIII before right trisegmentectomy is increasingly performed as a safe and effective concept to provide a proliferation stimulus (Fig. 1; cartoon on liver anatomy) . However, patients eligible for extended liver resection, such as those presented here, frequently suffer from large and fast progressing liver lesions, limiting the waiting time after PVE (observed to be up to 150 days ) to reach an adequate left lateral hepatic mass. Consequently, in some of these patients, PVE alone is insufficient to induce adequate proliferation of the left lateral FLRV in time for safe oncologic, extended liver resection.
Figure 1. Image outlining the distribution of hepatic segments. Parenchymal dissection along the falciform ligament as performed in extended right hepatectomy (trisegmentectomy) is shown.
To further accelerate liver proliferation levels, we consequently followed accumulating evidence for the contribution of extrahepatic stem cells (SCs) like hematopoietic progenitor cells participating in the concert of liver regeneration . Bone marrow (BM) cells have been shown experimentally to participate in liver proliferation after hepatic resection . Furthermore, it has been postulated that hematopoietic progenitor cells are able to transdifferentiate into both hepatocytes and bile duct cells . Mobilization of peripheral hematopoietic, CD34+ SCs (known to bear the capacity for differentiation into a hepatic lineage) after liver resection in oncologic patients has been demonstrated and was 10-fold higher compared with liver-sparing abdominal surgery . These data indicate a possible role for BM-derived SCs in liver proliferation after substantial loss of liver mass. Although as yet inconclusive, the therapeutic potential of hematopoietic SCs seems to be an attractive prospect for liver repair after acute or chronic hepatic injury .
CD133+ SCs were therapeutically used previously to support tissue and organ regeneration. Our center and others have used intramyocardial application of hematopoietic SCs enriched for CD133+ cells in various settings to promote the regeneration of postinfarction myocardium. In this study we report for the first time the therapeutic application of BM-derived SCs in humans with the intent to promote liver regeneration processes. CD133+ SCs highly enriched from autologous BM were selectively implanted to the left-lateral portal branches in three patients subsequent and in addition to selective PVE of contralateral liver segments I and IV to VIII.
PATIENTS AND METHODS
Characterization of CD133+ Cell Preparations
FACS analysis of native BM and the positive cell fraction after selection for CD133 (Table 1) are exemplified in detail for patient 3 in Figure 2. The calculated numbers of total intrahepatically administered CD133+ cells for patients 1, 2, and 3 were 8.8, 12.3, and 2.4 x 10E6 cells (Table 1).
Figure 2. Cytofluorimetric analyses of applied progenitor cells and gain of liver volume. Aliquots of unselected bone marrow (left panels) harvested from patients and the readministered positive fractions after enrichment for stem cell marker CD133 (right panels) were analyzed by fluorescence-activated cell sorting. Upper panels demonstrate the concentration of leukocytes detected by anti-CD45 antibodies. DNA-stain propidium iodide was used to assess rate of cell viability (middle panels). Using anti-CD133 and anti-CD34 antibodies (Miltenyi Biotec), the concentration for CD133+ cells was evaluated (lower panels). The characterization of samples derived from patient 3 is exemplified.
Gain of Left Lateral Liver Volume
Examples of hepatic CT scans are displayed for patient 2 before and after intervention in Figure 3A. CT scan–evaluated projected daily hepatic growth rates for patients 1, 2, and 3 were 10.6, 11.1, and 7.9 ml per day, resulting in a gain of the left lateral liver lobe of 51%, 122%, and 43% of the preinterventional left lateral liver volume after 22, 21, and 14 days after PVE plus SC treatment, respectively (Table 1). Determination of gain in volume of segments II/III in the reference group was based on a CT-volumetric evaluation pre-PVE contrasted with volumetric data gathered 22, 23, and 26 days after PVE, respectively (data not shown). The daily mean gain of the PVE plus BMSC application group with a mean gain of 9.87 ± 1.72 standard deviation (SD) in volume of hepatic segments II/III ranged well superior to the reference group, with a mean gain of 4.03 ml per day ± 0.47 SD (p < .01), as did the relative gain in percent of TLV (0.58 ± 0.118 SD versus 0.229 ± 0.019 SD; p < .01) (Fig. 3B).
Figure 3. Daily growth rates of hepatic segments II/III projected from computed tomography (CT) volumetry. (A): Transverse slices of CT scans obtained before (day 0) and 3 weeks after (day 21) PVE of hepatic segments I and IV to VIII plus intrahepatic application of CD133+ bone marrow cells to left lateral segments are shown as an example for patient 2. Black arrows indicate the tumor. White outline in CT scans indicates left lateral liver lobe. (B): Contrasting the mean of all three bone marrow SC patients (black columns) with that of three patients receiving the same protocol, including PVE, to expand the future liver remnant volume before extensive liver surgery except the application of bone marrow SCs in the same time period (white columns). Data are presented as mean ± standard deviation. **p < .01; Student’s t-test. Abbreviations: PVE, portal venous embolization; SC, stem cell; TLV, total liver volume.
Procedure-Related Adverse Events
There were no complications or reactions observed in the course of BM acquisition, PVE, and SC application. Wound infections developed in patients 1 and 2. Fever, observed for patient three 4 days after PVE, and SC application completely resolved 48 hours after initiation of an antibiotic therapy. Peak increase of serum transaminase levels after intervention was between 0 and 76 U/l. Serum bilirubin levels and coagulation parameters, like pro-thrombin time, activated partial thromboplastin time, and international normalized ratio (INR), remained normal.
Extended Hepatectomy Subsequent to PVE and Stem Cell Application
After recognition of a sufficient FLRV of segments II/III, right trisegmentectomy of the liver (segments I and IV to VIII) was performed in all three CD133+ cell–treated patients, with Rouxen-Y and bile duct reconstruction required for patients 1 and 2. Patient 2 revealed intraoperatively a primary neuroendocrine lesion of the appendix that was surgically treated by performing an ileocolic resection. A 1.0 x 0.5-cm tumor lesion of liver segment II was resected nonanatomically in this patient. Resection margins were free of tumor in all cases.
Patients were routinely kept in the intensive care unit for 2 days. Postoperative liver function demonstrated a mild insufficiency during the first days after surgery, assessed by total serum bilirubin (maximum, 2.7–6.6 mg/dl) and coagulation status (maximum INR, 1.8–1.9), mainly resolving by postoperative day 14 (Fig. 4). Markers of hepatocellular damage demonstrated a peak on days 2 and 3 (maximum aspartate amino transferase, 179–380 U/l; maximum amino alanine transferase, 272–466 U/l), quickly declining to almost reference levels by the second week postoperatively. Patient 1 developed a bile leakage requiring open reintervention. Patient 2 demonstrated a chylascos, spontaneously ceasing subsequent to a period of total parenteral nutrition.
Figure 4. Clinical chemistry before and early after extended right hepatectomy of patients receiving portal venous embolization (PVE) plus bone marrow stem cells (SCT) or PVE only. Upper panels: routinely assessed markers of liver metabolism (total serum bilirubin, black circles) and coagulation (INR; white circles), the latter representative for hepatic syntheses. Lower panels: aspartate amino transferase (AST; white circles) and amino alanine transferase (ALT; black circles) as markers of hepatocellular damage were evaluated. Abbreviation: INR, international normalized ratio.
Of non-CD133+–treated patients, 1 and 3 were never resected, due to development of tumor mass in the left lateral segment. On control patient 2, trisegmentectomy right plus partial pancreato-duodenectomy was performed, the latter to warrant resection margins to be tumor-free. The patient was depending on high positive end-expiratory pressure (PEEP) levels in the early course after surgery due to poor pulmonary performance. A portal vein thrombosis, most likely attributable to a PEEP-triggered compromised hepatic outflow, was resolved by revision of the portal vein. However, multiorgan failure led to death on the 10th postoperative day. Liver function markers for this patient are shown in Figure 4.
DISCUSSION
J.S.a.E. and W.T.K contributed equally to this manuscript.
REFERENCES
Iwatsuki S, Starzl TE. Personal experience with 411 hepatic resections. Ann Surg 1988;208:421–434.
Lai EC, Ng IO, You KT et al. Hepatectomy for large hepatocellular carcinoma: the optimal resection margin. World J Surg 1991;15:141–145.
Vauthey JN, Baer HU, Guastella T et al. Comparison of outcome between extended and nonextended liver resections for neoplasms. Surgery 1993;114:968–975.
Attiyeh FF, Wichern WA Jr. Hepatic resection for primary and metastatic tumors. Am J Surg 1988;156:368–373.
Brancatisano R, Isla A, Habib N. Is radical hepatic surgery safe? Am J Surg 1998;175:161–163.
Bozzetti F, Gennari L, Regalia E et al. Morbidity and mortality after surgical resection of liver tumors: analysis of 229 cases. Hepatogastroenterology 1992;39:237–241.
Cunningham JD, Fong Y, Shriver C et al. One hundred consecutive hepatic resections: blood loss, transfusion, and operative technique. Arch Surg 1994;129:1050–1056.
Hemming AW, Reed AI, Howard RJ et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003;237:686–691.
Broering DC, Hillert C, Krupski G et al. Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant. J Gastrointest Surg 2002;6:905–913.
Petersen BE, Bowen WC, Patrene KD et al. Bone marrow as a potential source of hepatic oval cells. Science 1999;284:1168–1170.
Theise ND, Badve S, Saxena R et al. Derivation of hepatocytes from bone marrow cells in mice after radiation-induced myeloablation. Hepatology 2000;31:235–240.
Alison MR, Poulsom R, Jeffery R et al. Hepatocytes from nonhepatic adult stem cells. Nature 2000;406:257.
Kollet O, Shivtiel S, Chen YQ et al. HGF, SDF-1, and MMP-9 are involved in stress-induced human CD34+ stem cell recruitment to the liver. J Clin Invest 2003;112:160–169.
FujiiH,HiroseT,OeSetal.Contributionofbonemarrowcellstoliverregeneration after partial hepatectomy in mice. J Hepatol 2002;36:653–659.
Lagasse E, Connors H, Al-Dhalimy M et al. Purified hematopoietic stem cells can differentiate into hepatocytes in vivo. Nat Med 2000;6:1229–1234.
Crosby HA, Kelly DA, Strain AJ. Human hepatic stem-like cells isolated using c-kit or CD34 can differentiate into biliary epithelium. Gastroenterology 2001;120:534–544.
Korbling M, Katz RL, Khanna A et al. Hepatocytes and epithelial cells of donor origin in recipients of peripheral-blood stem cells. N Engl J Med 2002;346:738–746.
Schwartz RE, Reyes M, Koodie L et al. Multipotent adult progenitor cells from bone marrow differentiate into functional hepatocyte-like cells. J Clin Invest 2002;109:1291–1302.
Newsome PN, Johannessen I, Boyle S et al. Human cord blood-derived cells can differentiate into hepatocytes in the mouse liver with no evidence of cellular fusion. Gastroenterology 2003;124:1891–1900.
De Silvestro G, Vicarioto M, Donadel C et al. Mobilization of peripheral blood hematopoietic stem cells following liver resection surgery. Hepatogastroenterology 2004;51:805–810.
Forbes SJ, Vig P, Poulsom R et al. Bone marrow-derived liver stem cells: their therapeutic potential. Gastroenterology 2002;123:654–655.
Theise ND. Liver stem cells: the fall and rise of tissue biology. Hepatology 2003;38:804–806.
Klein H-M, Ghodsizad A, Borowski A et al. Intramyocardial application of bone marrow derived stem cells in combination with transmyocardial laser revascularisation: report on two cases. Heart Surg Forum (in press).
Ghodsizad A, Klein H-M, Borowski A et al. Intramyocardial application of bone marrow derived stem cells in combination with transmyocardial laser revascularisation: report on two cases 2. Proceedings of 10th Cardiothoracic Techniques & Technologies 2004:A127.
Stamm C, Westphal B, Kleine HD et al. Autologous bone-marrow stem-cell transplantation for myocardial regeneration. Lancet 2003;361:45–46.
Pompilio G, Cannata A, Peccatori F et al. Autologous peripheral blood stem cells transplantation for myocardial regeneration: a novel strategy for cell collection and surgical injection. Proceedings of 10th Cardiothoracic Techniques & Technologies 2004:A125.
Nagasue N, Yukaya H, Ogawa Y et al. Human liver regeneration after major hepatic resection: a study of normal liver and livers with chronic hepatitis and cirrhosis. Ann Surg 1987;206:30–39.
Ghodsizad A, Klein H-M, Borowski A et al. Intraoperative isolation and processing of bone marrow derived stem cell. Cytotherapie 2004;6:523–526.
Gehling UM, Willems M, Schlagner K et al. Partial hepatectomy induces mobilization of a distinct population of progenitor cells in healthy liver donors. J Hepatol 2004;40:19.
Hatch HM, Zheng D, Jorgensen ML et al. SDF-1alpha/CXCR4: a mechanism for hepatic oval cell activation and bone marrow stem cell recruitment to the injured liver of rats. Cloning Stem Cells 2002;4:339–351.
Wang X, Ge S, McNamara G et al. Albumin-expressing hepatocyte-like cells develop in the livers of immune-deficient mice that received transplants of highly purified human hematopoietic stem cells. Blood 2003;101:4201–4208.
Kubota K, Makuuchi M, Kusaka K et al. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology 1997;26:1176–1181.
Yannaki E, Athanasiou E, Xagorari A et al. Transplantation of mobilized peripheral blood stem cells in unconditioned hosts results in formation of donor-derived hepatocytes in an experimental liver injury model. Blood 2003;102:1213.
Wang X, Willenbring H, Akkari Y et al. Cell fusion is the principal source of bone-marrow-derived hepatocytes. Nature 2003;422:897–901.
Vassilopoulos G, Wang PR, Russell DW. Transplanted bone marrow regenerates liver by cell fusion. Nature 2003;422:901–904.
Jang YY, Collector MI, Baylin SB et al. Hematopoietic stem cells convert into liver cells within days without fusion. Nat Cell Biol 2004;6:532–539.
Grisham JW, Hartroft WS. Morphologic identification by electron microscopy of "oval" cells in experimental hepatic degeneration. Lab Invest 1961;10:317–332.
Koukoulis G, Rayner A, Tan KC et al. Immunolocalization of regenerating cells after submassive liver necrosis using PCNA staining. J Pathol 1992;166:359–368.
De Vos R, Desmet V. Ultrastructural characteristics of novel epithelial cell types identified in human pathologic liver specimens with chronic ductular reaction. Am J Pathol 1992;140:1441–1450.
Golding M, Sarraf CE, Lalani EN et al. Oval cell differentiation into hepatocytes in the acetylaminofluorene-treated regenerating rat liver. Hepatology 1995;22:1243–1253.
Yin L, Lynch D, Sell S. Participation of different cell types in the restitutive response of the rat liver to periportal injury induced by allyl alcohol. J Hepatol 1999;31:497–507.
Alison MR, Golding M, Sarraf CE. Liver stem cells: when the going gets tough they get going. Int J Exp Pathol 1997;78:365–381.
Bustos M, Sangro B, Alzuguren P et al. Liver damage using suicide genes: a model for oval cell activation. Am J Pathol 2000;157:549–559.
Fan TX, Hisha H, Jin TN et al. Successful allogeneic bone marrow transplantation (BMT) by injection of bone marrow cells via portal vein: stromal cells as BMT-facilitating cells. STEM CELLS 2001;19:144–150.33(Jan Schulte am Esch, IIa,)
b Cardiothoracic Surgery,
c Diagnostic Radiology,
d Hemostaseology and Transfusion Medicine, and
e Gastroenterology, Hepatology, and Infectious Diseases, Heinrich-Heine-University of Duesseldorf, Duesseldorf, Germany,
f Institute of Clinical Pharmacology, University of Witten/Herdecke, Witten, Germany
Key Words. Adult bone marrow stem cells ? Liver regeneration ? AC133 antigen ? Somatic cell therapy ? Clinical trials ? Clinical stem cell transplantation
Correspondence: Wolfram Trudo Knoefel, M.D., F.A.C.S., Department of General Surgery, Heinrich-Heine-University of Duesseldorf, Moorenstrasse 5, D-40225 Duesseldorf, Germany. Telephone: 49-211-8117350/51; Fax: 49-211-8117359; e-mail: knoefel@uni-duesseldorf.de
ABSTRACT
In up to 45% of patients with primary or secondary liver tumors, extended hepatectomy (greater than five segments) is necessary to achieve tumor-negative resection margins . However, patients with an anticipated future liver remnant volume (FLRV) below 20%–25% of total liver volume (TLV) have an increased incidence of postoperative morbidity and mortality . The concept of preoperative expansion of the left-lateral FLRV (segments II and III) using selective portal venous embolization (PVE) of contralateral liver segments I and IV to VIII before right trisegmentectomy is increasingly performed as a safe and effective concept to provide a proliferation stimulus (Fig. 1; cartoon on liver anatomy) . However, patients eligible for extended liver resection, such as those presented here, frequently suffer from large and fast progressing liver lesions, limiting the waiting time after PVE (observed to be up to 150 days ) to reach an adequate left lateral hepatic mass. Consequently, in some of these patients, PVE alone is insufficient to induce adequate proliferation of the left lateral FLRV in time for safe oncologic, extended liver resection.
Figure 1. Image outlining the distribution of hepatic segments. Parenchymal dissection along the falciform ligament as performed in extended right hepatectomy (trisegmentectomy) is shown.
To further accelerate liver proliferation levels, we consequently followed accumulating evidence for the contribution of extrahepatic stem cells (SCs) like hematopoietic progenitor cells participating in the concert of liver regeneration . Bone marrow (BM) cells have been shown experimentally to participate in liver proliferation after hepatic resection . Furthermore, it has been postulated that hematopoietic progenitor cells are able to transdifferentiate into both hepatocytes and bile duct cells . Mobilization of peripheral hematopoietic, CD34+ SCs (known to bear the capacity for differentiation into a hepatic lineage) after liver resection in oncologic patients has been demonstrated and was 10-fold higher compared with liver-sparing abdominal surgery . These data indicate a possible role for BM-derived SCs in liver proliferation after substantial loss of liver mass. Although as yet inconclusive, the therapeutic potential of hematopoietic SCs seems to be an attractive prospect for liver repair after acute or chronic hepatic injury .
CD133+ SCs were therapeutically used previously to support tissue and organ regeneration. Our center and others have used intramyocardial application of hematopoietic SCs enriched for CD133+ cells in various settings to promote the regeneration of postinfarction myocardium. In this study we report for the first time the therapeutic application of BM-derived SCs in humans with the intent to promote liver regeneration processes. CD133+ SCs highly enriched from autologous BM were selectively implanted to the left-lateral portal branches in three patients subsequent and in addition to selective PVE of contralateral liver segments I and IV to VIII.
PATIENTS AND METHODS
Characterization of CD133+ Cell Preparations
FACS analysis of native BM and the positive cell fraction after selection for CD133 (Table 1) are exemplified in detail for patient 3 in Figure 2. The calculated numbers of total intrahepatically administered CD133+ cells for patients 1, 2, and 3 were 8.8, 12.3, and 2.4 x 10E6 cells (Table 1).
Figure 2. Cytofluorimetric analyses of applied progenitor cells and gain of liver volume. Aliquots of unselected bone marrow (left panels) harvested from patients and the readministered positive fractions after enrichment for stem cell marker CD133 (right panels) were analyzed by fluorescence-activated cell sorting. Upper panels demonstrate the concentration of leukocytes detected by anti-CD45 antibodies. DNA-stain propidium iodide was used to assess rate of cell viability (middle panels). Using anti-CD133 and anti-CD34 antibodies (Miltenyi Biotec), the concentration for CD133+ cells was evaluated (lower panels). The characterization of samples derived from patient 3 is exemplified.
Gain of Left Lateral Liver Volume
Examples of hepatic CT scans are displayed for patient 2 before and after intervention in Figure 3A. CT scan–evaluated projected daily hepatic growth rates for patients 1, 2, and 3 were 10.6, 11.1, and 7.9 ml per day, resulting in a gain of the left lateral liver lobe of 51%, 122%, and 43% of the preinterventional left lateral liver volume after 22, 21, and 14 days after PVE plus SC treatment, respectively (Table 1). Determination of gain in volume of segments II/III in the reference group was based on a CT-volumetric evaluation pre-PVE contrasted with volumetric data gathered 22, 23, and 26 days after PVE, respectively (data not shown). The daily mean gain of the PVE plus BMSC application group with a mean gain of 9.87 ± 1.72 standard deviation (SD) in volume of hepatic segments II/III ranged well superior to the reference group, with a mean gain of 4.03 ml per day ± 0.47 SD (p < .01), as did the relative gain in percent of TLV (0.58 ± 0.118 SD versus 0.229 ± 0.019 SD; p < .01) (Fig. 3B).
Figure 3. Daily growth rates of hepatic segments II/III projected from computed tomography (CT) volumetry. (A): Transverse slices of CT scans obtained before (day 0) and 3 weeks after (day 21) PVE of hepatic segments I and IV to VIII plus intrahepatic application of CD133+ bone marrow cells to left lateral segments are shown as an example for patient 2. Black arrows indicate the tumor. White outline in CT scans indicates left lateral liver lobe. (B): Contrasting the mean of all three bone marrow SC patients (black columns) with that of three patients receiving the same protocol, including PVE, to expand the future liver remnant volume before extensive liver surgery except the application of bone marrow SCs in the same time period (white columns). Data are presented as mean ± standard deviation. **p < .01; Student’s t-test. Abbreviations: PVE, portal venous embolization; SC, stem cell; TLV, total liver volume.
Procedure-Related Adverse Events
There were no complications or reactions observed in the course of BM acquisition, PVE, and SC application. Wound infections developed in patients 1 and 2. Fever, observed for patient three 4 days after PVE, and SC application completely resolved 48 hours after initiation of an antibiotic therapy. Peak increase of serum transaminase levels after intervention was between 0 and 76 U/l. Serum bilirubin levels and coagulation parameters, like pro-thrombin time, activated partial thromboplastin time, and international normalized ratio (INR), remained normal.
Extended Hepatectomy Subsequent to PVE and Stem Cell Application
After recognition of a sufficient FLRV of segments II/III, right trisegmentectomy of the liver (segments I and IV to VIII) was performed in all three CD133+ cell–treated patients, with Rouxen-Y and bile duct reconstruction required for patients 1 and 2. Patient 2 revealed intraoperatively a primary neuroendocrine lesion of the appendix that was surgically treated by performing an ileocolic resection. A 1.0 x 0.5-cm tumor lesion of liver segment II was resected nonanatomically in this patient. Resection margins were free of tumor in all cases.
Patients were routinely kept in the intensive care unit for 2 days. Postoperative liver function demonstrated a mild insufficiency during the first days after surgery, assessed by total serum bilirubin (maximum, 2.7–6.6 mg/dl) and coagulation status (maximum INR, 1.8–1.9), mainly resolving by postoperative day 14 (Fig. 4). Markers of hepatocellular damage demonstrated a peak on days 2 and 3 (maximum aspartate amino transferase, 179–380 U/l; maximum amino alanine transferase, 272–466 U/l), quickly declining to almost reference levels by the second week postoperatively. Patient 1 developed a bile leakage requiring open reintervention. Patient 2 demonstrated a chylascos, spontaneously ceasing subsequent to a period of total parenteral nutrition.
Figure 4. Clinical chemistry before and early after extended right hepatectomy of patients receiving portal venous embolization (PVE) plus bone marrow stem cells (SCT) or PVE only. Upper panels: routinely assessed markers of liver metabolism (total serum bilirubin, black circles) and coagulation (INR; white circles), the latter representative for hepatic syntheses. Lower panels: aspartate amino transferase (AST; white circles) and amino alanine transferase (ALT; black circles) as markers of hepatocellular damage were evaluated. Abbreviation: INR, international normalized ratio.
Of non-CD133+–treated patients, 1 and 3 were never resected, due to development of tumor mass in the left lateral segment. On control patient 2, trisegmentectomy right plus partial pancreato-duodenectomy was performed, the latter to warrant resection margins to be tumor-free. The patient was depending on high positive end-expiratory pressure (PEEP) levels in the early course after surgery due to poor pulmonary performance. A portal vein thrombosis, most likely attributable to a PEEP-triggered compromised hepatic outflow, was resolved by revision of the portal vein. However, multiorgan failure led to death on the 10th postoperative day. Liver function markers for this patient are shown in Figure 4.
DISCUSSION
J.S.a.E. and W.T.K contributed equally to this manuscript.
REFERENCES
Iwatsuki S, Starzl TE. Personal experience with 411 hepatic resections. Ann Surg 1988;208:421–434.
Lai EC, Ng IO, You KT et al. Hepatectomy for large hepatocellular carcinoma: the optimal resection margin. World J Surg 1991;15:141–145.
Vauthey JN, Baer HU, Guastella T et al. Comparison of outcome between extended and nonextended liver resections for neoplasms. Surgery 1993;114:968–975.
Attiyeh FF, Wichern WA Jr. Hepatic resection for primary and metastatic tumors. Am J Surg 1988;156:368–373.
Brancatisano R, Isla A, Habib N. Is radical hepatic surgery safe? Am J Surg 1998;175:161–163.
Bozzetti F, Gennari L, Regalia E et al. Morbidity and mortality after surgical resection of liver tumors: analysis of 229 cases. Hepatogastroenterology 1992;39:237–241.
Cunningham JD, Fong Y, Shriver C et al. One hundred consecutive hepatic resections: blood loss, transfusion, and operative technique. Arch Surg 1994;129:1050–1056.
Hemming AW, Reed AI, Howard RJ et al. Preoperative portal vein embolization for extended hepatectomy. Ann Surg 2003;237:686–691.
Broering DC, Hillert C, Krupski G et al. Portal vein embolization vs. portal vein ligation for induction of hypertrophy of the future liver remnant. J Gastrointest Surg 2002;6:905–913.
Petersen BE, Bowen WC, Patrene KD et al. Bone marrow as a potential source of hepatic oval cells. Science 1999;284:1168–1170.
Theise ND, Badve S, Saxena R et al. Derivation of hepatocytes from bone marrow cells in mice after radiation-induced myeloablation. Hepatology 2000;31:235–240.
Alison MR, Poulsom R, Jeffery R et al. Hepatocytes from nonhepatic adult stem cells. Nature 2000;406:257.
Kollet O, Shivtiel S, Chen YQ et al. HGF, SDF-1, and MMP-9 are involved in stress-induced human CD34+ stem cell recruitment to the liver. J Clin Invest 2003;112:160–169.
FujiiH,HiroseT,OeSetal.Contributionofbonemarrowcellstoliverregeneration after partial hepatectomy in mice. J Hepatol 2002;36:653–659.
Lagasse E, Connors H, Al-Dhalimy M et al. Purified hematopoietic stem cells can differentiate into hepatocytes in vivo. Nat Med 2000;6:1229–1234.
Crosby HA, Kelly DA, Strain AJ. Human hepatic stem-like cells isolated using c-kit or CD34 can differentiate into biliary epithelium. Gastroenterology 2001;120:534–544.
Korbling M, Katz RL, Khanna A et al. Hepatocytes and epithelial cells of donor origin in recipients of peripheral-blood stem cells. N Engl J Med 2002;346:738–746.
Schwartz RE, Reyes M, Koodie L et al. Multipotent adult progenitor cells from bone marrow differentiate into functional hepatocyte-like cells. J Clin Invest 2002;109:1291–1302.
Newsome PN, Johannessen I, Boyle S et al. Human cord blood-derived cells can differentiate into hepatocytes in the mouse liver with no evidence of cellular fusion. Gastroenterology 2003;124:1891–1900.
De Silvestro G, Vicarioto M, Donadel C et al. Mobilization of peripheral blood hematopoietic stem cells following liver resection surgery. Hepatogastroenterology 2004;51:805–810.
Forbes SJ, Vig P, Poulsom R et al. Bone marrow-derived liver stem cells: their therapeutic potential. Gastroenterology 2002;123:654–655.
Theise ND. Liver stem cells: the fall and rise of tissue biology. Hepatology 2003;38:804–806.
Klein H-M, Ghodsizad A, Borowski A et al. Intramyocardial application of bone marrow derived stem cells in combination with transmyocardial laser revascularisation: report on two cases. Heart Surg Forum (in press).
Ghodsizad A, Klein H-M, Borowski A et al. Intramyocardial application of bone marrow derived stem cells in combination with transmyocardial laser revascularisation: report on two cases 2. Proceedings of 10th Cardiothoracic Techniques & Technologies 2004:A127.
Stamm C, Westphal B, Kleine HD et al. Autologous bone-marrow stem-cell transplantation for myocardial regeneration. Lancet 2003;361:45–46.
Pompilio G, Cannata A, Peccatori F et al. Autologous peripheral blood stem cells transplantation for myocardial regeneration: a novel strategy for cell collection and surgical injection. Proceedings of 10th Cardiothoracic Techniques & Technologies 2004:A125.
Nagasue N, Yukaya H, Ogawa Y et al. Human liver regeneration after major hepatic resection: a study of normal liver and livers with chronic hepatitis and cirrhosis. Ann Surg 1987;206:30–39.
Ghodsizad A, Klein H-M, Borowski A et al. Intraoperative isolation and processing of bone marrow derived stem cell. Cytotherapie 2004;6:523–526.
Gehling UM, Willems M, Schlagner K et al. Partial hepatectomy induces mobilization of a distinct population of progenitor cells in healthy liver donors. J Hepatol 2004;40:19.
Hatch HM, Zheng D, Jorgensen ML et al. SDF-1alpha/CXCR4: a mechanism for hepatic oval cell activation and bone marrow stem cell recruitment to the injured liver of rats. Cloning Stem Cells 2002;4:339–351.
Wang X, Ge S, McNamara G et al. Albumin-expressing hepatocyte-like cells develop in the livers of immune-deficient mice that received transplants of highly purified human hematopoietic stem cells. Blood 2003;101:4201–4208.
Kubota K, Makuuchi M, Kusaka K et al. Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors. Hepatology 1997;26:1176–1181.
Yannaki E, Athanasiou E, Xagorari A et al. Transplantation of mobilized peripheral blood stem cells in unconditioned hosts results in formation of donor-derived hepatocytes in an experimental liver injury model. Blood 2003;102:1213.
Wang X, Willenbring H, Akkari Y et al. Cell fusion is the principal source of bone-marrow-derived hepatocytes. Nature 2003;422:897–901.
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