Laparoscopic minor liver resection for hepatocellular carcinoma.

BACKGROUND: Previous studies have suggested that laparoscopic liver resection for hepatocellular carcinoma is associated with lower postoperative complications compared with open liver resection. METHODS: We conducted a retrospective analysis of 109 hepatocellular carcinoma patients who underwent minor liver resection at a Japanese tertiary care hospital from November 2010 to December 2022. RESULTS: The laparoscopic liver resection group experienced significantly lower median intraoperative blood loss compared with the open liver resection group (P = 0.0001). Furthermore, the laparoscopic liver resection group had a significantly shorter median hospital stay compared with the open liver resection group (P = 0.0002). However, there was no significant difference in median postoperative survival between the laparoscopic liver resection group and the open liver resection group (P = 0.717). CONCLUSIONS: Laparoscopic minor liver resection for hepatocellular carcinoma resulted in reduced blood loss and hospital stay without compromising long-term survival outcomes.

Preoperative neutrophil-to-lymphocyte ratio may contribute to the prediction of postoperative infectious complications in patients with acute appendicitis: a retrospective study.

BACKGROUND: Several studies have assessed various clinical variables to identify risk factors for postoperative complications in patients with acute appendicitis. However, few studies have focused on the relationships between systemic inflammatory variables and postoperative complications in patients with acute appendicitis. We investigated the relationships between postoperative complications and systemic inflammatory variables, and assessed the clinical utility of these variables as predictors of postoperative complications in patients with acute appendicitis. METHODS: We retrospectively reviewed 181 patients who underwent immediate appendectomy for acute appendicitis. All postoperative complications were classified as infectious or noninfectious, and we evaluated the relationships between postoperative complications and clinical factors including the preoperative neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio. RESULTS: In total, 28 patients (15.5%) had postoperative Clavien-Dindo grade II-IV complications; 17 patients (9.4%) and 11 patients (6.1%) were categorized as the infectious and noninfectious complication groups, respectively. The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for all complications was 11.3, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of any postoperative complication (odds ratio: 4.223, 95% confidence interval: 1.335-13.352; P = 0.014). The cutoff value of the preoperative neutrophil-to-lymphocyte ratio for infectious complications was 11.4, and multivariate analysis revealed that the preoperative neutrophil-to-lymphocyte ratio was an independent predictor of infectious complications (odds ratio: 4.235, 95% confidence interval: 1.137-15.776; P = 0.031). CONCLUSIONS: In patients with acute appendicitis, the preoperative neutrophil-to-lymphocyte ratio may be a useful predictor of all postoperative complications, especially infectious complications.

[Laparoscopic Right-Sided Colon Cancer Surgery Using Pancreas/Duodenum 3DCT(PDCT)].

BACKGROUND AND PURPOSE: The right colic artery(RCA)and gastrocolic trunk(GCT)traverse around the pancreas and duodenum and branch divergently, thus, complicating right-sided colon cancer surgery. The usefulness of pancreatic/duodenum 3DCT imaging(pancreas/duodenum CT: PDCT)for laparoscopic right-sided colon cancer surgery was investigated. PATIENT AND METHOD: The patient was a woman, in her 80's with 2 sites of ascending colon cancer:(1)A-C, cT4b(retroperitoneum) N2aM0, Stage Ⅲc;(2)A, cT3N1bM0, Stage Ⅲb. A radical surgery was planned. Contrast-enhanced CT colonography( CTC)was performed preoperatively, and 3 3DCT images(CTC, arteriovenous 3DCT, and PDCT)were created using Workstation: Ziostation 2®(Ziosoft). These 3DCT images were combined and used for preoperative simulation and intraoperative navigation. RESULT: Composite images of CTC and arterial 3DCT identified the dominance of ileocolic artery(ICA)and RCA. In addition, a composite venous 3DCT image confirmed the branching and course of ileocolic vein(ICV)and right colic vein(RCV). Composite images of PDCT and arteriovenous 3DCT showed that the RCA branched from the superior mesenteric artery at the level of the third part of duodenum and ran ventral to the pancreatic head, while the RCV branched from the GCT in front of the pancreatic head, with the right gastroepiploic vein(RGEV). A laparoscopic combined ileal and retroperitoneal resection and D3 lymph node dissection with ICA/V and RCA/V root dissection were planned. Surgical simulation facilitated the identification of ICA/V and RCA/V and surgical procedure. The operative time was 310 minutes, and blood loss was 90 mL. Histopathological examination confirmed the diagnosis of(1)pT3(SS)N1bM0, Stage Ⅲb and(2)pT3 (SS)N1aM0, Stage Ⅲb. The patient was discharged 10 days post-surgery, without any complications. Currently, there is no apparent recurrence at 1-year follow-up. CONCLUSION: PDCT clarified the location of the RCA and GCT in relation to the pancreas and duodenum and complemented the laparoscopic right-sided colon cancer surgery.

[Stoma Site Marking of Colostomy Using Colostomy Simulation 3D-CT-A Case Report].

BACKGROUND AND PURPOSE: Stoma site marking is performed by inspection and palpation of the body surface. In stoma site, it is estimated that transverse colon is epigastric lesion and sigmoid colon is left hypogastric lesion. We try making colostomy simulation(Cs)3D-CT by which stoma site marking is able to be performed considering exact form of colon. PATIENT AND METHOD: The patient was 50s man with advanced rectal cancer and unresectable multiple liver metastases. Colonostomy was scheduled for strong rectal stenosis. Standard contrast-enhanced CT scan was performed before operation, and 3D-CT imaging was maked using Workstation Ziostation2(ziosoft, Tokyo, Japan). 3D-CT imaging of abdominal wall was maked by synthesizing 3D-CT imaging of body surface and rectus abdominis muscle. Cs3D-CT is maked by synthesizing CT colonography and 3D-CT imaging of abdominal wall. RESULT: The simulation of stoma site marking was performed using Cs3D-CT. Inferior epigastric artery(IEA)was identified, it was to simulate elevated colons and the stoma sites to enable easy elevation of colon through rectus abdominis muscle avoiding injury of IEA. It was possible to measure the distance from navel to stoma site marking on 3D-CT imaging, final stoma site marking was decided by applying the simulation to real stoma site marking. The difficulty of operation was assessed from positional relationship between colon and abdominal wall. It seemed to be relatively easy to elevate sigmoid colon because sigmoid colon was directly under the rectus abdominis muscle. Sigmoidostomy was scheduled considering rectal cancer, and trephine sigmoidostomy with double orifices was performed in fact. CONCLUSION: Cs3D-CT was possible to simulate colostomy considering the exact form of colon and positional relationship to abdominal wall and to perform stoma site marking considering the exact form of rectus abdominis muscle and position of IEA. Using Cs3D-CT, it seems to be able to perform optimal stoma site marking which is difficult by conventional method.

Development of Pancreatic Cancer, Disease-specific Mortality, and All-Cause Mortality in Patients with Nonresected IPMNs: A Long-term Cohort Study.

PURPOSE: To determine the cumulative incidence, disease-specific mortality, and all-cause mortality of pancreatic cancer (PC) in patients with intraductal papillary mucinous neoplasms (IPMNs) and to identify imaging findings that are associated with these outcomes. MATERIALS AND METHODS: This retrospective study had institutional review board approval, and the need to obtain patient consent was waived. Data from an electronic database were analyzed and supplemented by chart reviews for 285 patients with nonresected IPMNs who were periodically followed up with imaging (1273 multidetector computed tomography and 750 magnetic resonance cholangiopancreatography examinations). The Kaplan-Meier method was used to estimate the cumulative development of PC, PC mortality, and all-cause mortality (factors were compared by using the log-rank test). RESULTS: Over a median imaging follow-up period of 39 months, 12 (4.2%) of 285 patients developed PC; the cumulative 5-year PC incidence was 3.9% for branch duct (BD)-IPMNs, 45.5% for main duct (MD)-IPMNs (P < .01), 7.7% for cysts 30 mm or larger, and 5.3% for cysts smaller than 30 mm (P = .82). Over a median survival follow-up period of 47.5 months, seven (2.5%) of 285 patients died of PC and 14 (4.9%) patients died of other causes. Cumulative 5-year PC mortality was 2.1% for BD-IPMNs, 18.5% for MD-IPMNs (P < .01), 2.6% for cysts 30 mm or larger, and 2.8% for cysts smaller than 30 mm (P = .90). Cumulative 5-year all-cause mortality was 5.5% for BD-IPMNs, 18.5% for MD-IPMNs (P < .01), 12.5% for cysts 30 mm or larger, and 5.9% for cysts smaller than 30 mm (P = .89). CONCLUSION: Five-year PC development, disease-specific mortality, and all-cause mortality were approximately 4%, 2%, and 6% for BD-IPMNs and 46%, 19%, and 19% for MD-IPMNs, respectively. The presence of an MD-IPMN, but not cyst size, was significantly associated with PC development and subsequent mortality.

A case of malignant insulinoma: successful control of glycemic fluctuation by replacing octreotide injections with octreotide LAR injections.

A 73-year-old woman with malignant insulinoma was treated with 100 µg/day octreotide for unresected insulinoma and liver metastases. The daily administration of the drug induced hyperglycemia after dinner in addition to existing fasting hypoglycemia possibly because this drug suppressed both insulin and glucagon secretion and its blood concentration was unstable. After replacing a daily injection of octreotide with a monthly injection of octreotide long-acting repeatable (LAR), blood glucose levels stabilized within the normal range. The findings of the present study showed that octreotide LAR could be useful for the long-term treatment of unresectable insulinomas.

Registration between 2D and 3D Ultrasound Images to Track Liver Blood Vessel Movement.

BACKGROUND: For the accurate positioning of surgical tools, conventional intraoperative navigation systems have been developed to recognize the relationship between target positions and the tools. However, since an internal organ is deformed during the operation, registration between realtime two-dimensional (2D) ultrasound images and three-dimensional (3D) CT or MRI images is not always effective. Therefore, this study developed image registration between 2D and 3D ultrasound images considering deformation for tracking target vessel movement in the liver. METHODS: 3D ultrasound image was obtained in advance with 3D coordinates, including the target vessel. Then real-time 2D images and ultrasound probe position were simultaneously acquired using a 3D position sensor. We applied multiple image resolution registration, where rapid and fine optimizations can be expected at higher and lower levels, respectively. Meanwhile, the gradient descent method was adopted for the optimization, which determines the relative arrangements to obtain maximum similarity between 2D and 3D images. We experimentally established resolution level parameters using a phantom before applying it to track liver blood vessel movements in a normal healthy subject. RESULTS: Comparing the 2D images and the registered images, although the approach has some limitations in tracking large displacement, we confirmed that the cross-section of the target blood vessel was clearly visualized. CONCLUSION: This method has the potential for an ultrasound therapy targeting blood vessels under natural respiration conditions.

Quality of life after total pancreatectomy with islet autotransplantation for chronic pancreatitis in Japan.

BACKGROUND: Patients with chronic pancreatitis (CP) often have severe and intractable abdominal pain, leading to decreased quality of life (QOL), inability to work or attend school, and increased health care costs due to repeated emergency room visits and hospitalizations. METHODS: We evaluated the efficacy of total pancreatectomy and islet autotransplantation (TPIAT) in terms of pain control and QOL in CP patients treated at our center in Japan. To evaluate QOL, we used the Short-Form 36 Health Survey version 2 (SF-36v2® Standard, Japanese), European Organization for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30), and Quality of Life Questionnaire-Pancreatic Modification (QLQ-PAN28). RESULTS: Between August 2016 and June 2019, we performed this procedure in 5 patients. All patients were followed up for 12 months and all transplanted islets were still functioning at the 1-year follow-up. The major adverse events were abdominal wall hemorrhage, intestinal obstruction, intra-abdominal abscess, and abdominal pain requiring hospitalization; no case had sequelae. No major complications were due to islet transplantation. Pain scores improved postoperatively in all patients. Three QOL item dimensions role-physical (p = 0.03125), general health perception (p = 0.03125) and vitality (p = 0.03125) in the SF-36 were significantly improved 12 months after TPIAT. Mean values of many other QOL items improved, though not significantly. CONCLUSION: The QOL improvement after TPIAT for CP suggests its effectiveness in the Japanese population.

Allogeneic islet transplantation with monitoring of islet-specific cellular autoimmunity in a Japanese patient with type 1 diabetes: A case report.

Here, we report a case of allogeneic islet transplantation in Japan. A 48-year-old man received intraportal islet transplantation (5,945 islet equivalent/kg), and stabilization of blood glucose levels and suppression of hypoglycemia were achieved. In the present case, we used our original assessment method to detect the responses of the recipient's T cells to islet autoantigens over time to monitor cellular autoimmunity. Other markers could not predict graft dysfunction in advance, but our method detected the activation of islet antigen-specific CD8+ T-cell responses before the deterioration of pancreatic ß-cell function, indicating the possibility of the non-invasive detection of pancreatic ß-cell damage due to recurrent autoimmunity.

Two cases of central venous catheter-related thrombosis in living liver donors: how can the risk be minimized?

A central venous catheter (CVC) is commonly used for intraoperative management by anesthetists and surgeons during major operations, including donor operations for living donor liver transplantation (LDLT), in which donor safety is of utmost importance. Reasons for use of CVC for donors include measurement of central venous pressure and drug infusion when necessary. A potentially serious complication of a major operation is pulmonary thromboembolism. We report two cases of LDLT donors complicated by catheter related thrombosis (CRT) of the jugular vein, who were eventually discharged without long-term complications. To the best of our knowledge, there has been no report of CRT among LDLT donor population. In this report, in order to minimize the risks related to CRT in LDLT donors, we propose thorough screening for thrombophilic disorders, use of a silicone or polyurethane double-lumen CVC as thin as possible, placement of the tip of the CVC at the superior vena cava via the right jugular vein using ultrasonography as a guide for puncture, and removal of the catheter at the end of the operation based on our experience of CRT among LDLT donors.

Three-dimensional extension of blood vessel network by combining multiple ultrasound volumes from different directions.

We have previously proposed the use of acoustic radiation force in blood vessels for therapeutic application of ultrasound. For this purpose, we have developed a blood vessel network reconstruction algorithm to fuse between B-mode and Doppler-mode volumes. However, a size of ultrasound volume was insufficient to recognize the network for treatment. Therefore, using multiple ultrasound volumes, we propose a method to extend a network with neighbor networks. First, an ultrasound volume was analyzed to extract tree-structure including the nodes and the edges. Then we configured an extension method between two tree-structures, which performs the insertion of nodes in a source tree to a target tree. Next, similarity between two networks were evaluated by introducing edge lengths in the network and the edit distance. By analyzing in vivo blood vessel of porcine liver, we confirmed that the construction of the network was reliable according to the extension with the similarity of 60% compared with CT data. We confirmed that the proposed method is effective for reconstructing blood vessel network.

Characterization of erythrovirus B19 genomes isolated in liver tissues from patients with fulminant hepatitis and biliary atresia who underwent liver transplantation.

BACKGROUND: Fulminant hepatitis and biliary atresia are serious problems and their causes have not been explained well. We investigated whether or not erythrovirus B19 is a candidate etiologic agent in such liver disease patients who had undergone liver transplantation. METHODS: Liver tissues from 47 patients consisted of 28 fulminant hepatitis and 19 biliary atresia were examined to detect B19 genes by PCR and further analyzed their genomic characterization. RESULTS: B19 DNA was detected by nested PCR in 10 of 28 cases (35.7%) livers in the fulminant hepatitis group and 7 of 19 (36.8%) livers in the biliary atresia group, respectively (statistically not significant). Importantly, among the 8 hepatic B19 DNA-positive patients who had paired samples of liver and serum, the serum B19 genome was detectable in only one case. B19 mRNA was identified in all of 10 fulminant hepatitis cases with hepatic B19 DNA, but only 1 out of 7 (14.3%) cases in biliary atresia tested. Furthermore, we obtained ten isolates having the B19 genome with nearly full-length sequences. Interestingly, phylogenetic analysis based on the NS1 gene revealed three different clusters: two for isolates from fulminant hepatitis and the other for isolates from biliary atresia. CONCLUSIONS: Our results presented here suggested that B19 may be an etiologic agent of fulminant hepatitis.

Geographic characterization of hepatitis virus infections, genotyping of hepatitis B virus, and p53 mutation in hepatocellular carcinoma analyzed by in situ detection of viral genomes from carcinoma tissues: comparison among six different countries.

We investigated the relationship of infection with hepatitis B virus (HBV) and hepatitis C virus (HCV) to p53 mutation in hepatocellular carcinomas (HCC) from six countries, including Japan, China, Korea, Vietnam, Spain, and the Unites States. For this purpose, we used formalin-fixed, paraffin-embedded liver tissues obtained from 449 patients with HCC to detect the viral and p53 genes by polymerase chain reaction (PCR). HBV was the most prevalent in Korea (69.1%), China (66.1%), Vietnam (60.5%), and Spain (38.6%). In contrast, HCV was the most prevalent in Japan (59.8%) and in the United States (41.5%). Type C of HBV was the most common genotype (78.6%) encountered in HCC in these countries. Importantly, among 125 intrahepatic HBV DNA-positive patients, 44 (35.2%) were serologically negative for HBsAg (occult hepatitis B). Based on PCR, immunohistochemical, serological, and clinical findings, 4.8% of HCC patients were diagnosed with non-B, non-C. A point mutation at exon 7 of p53 was detected in 20 of the 239 HCC samples examined, including those from 9 Chinese, 5 American, 2 Japanese, 2 Korean, and 2 Spanish patients, respectively. Interestingly, a point mutation with an amino acid substitution at codon 251 (Ile-->Asn) was detected frequently in 11 of 20 (55%) cases. A specific mutation induced by Aflatoxin B1 at codon 249 was seen in two patients, both Chinese. Our results suggest that genotype C of HBV may play an important role in hepatocarcinogenesis in different geographic regions, and that in situ detection of HBV genomes could be important for clarifying the agent(s) of unknown etiology related to HCC.

Liver analysis using gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid-enhanced magnetic resonance imaging: Correlation with histological grading and quantitative liver evaluation prior to hepatectomy.

AIM: To examine the effectiveness of gadolinium-ethoxybenzyl-diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in the assessment of parenchymal liver fibrosis and quantitative liver function prior to hepatectomy. METHODS: Between July 2008 and September 2011, the data of 93 consecutive patients undergoing preoperative Gd-EOB-DTPA-enhanced MRI were analyzed, including serum fibrosis marker levels (hyaluronic acid, type IV collagen), 15-min retention rates of indocyanine green (ICG-R15) in the ICG clearance test, and technetium-99m galactosyl serum albumin scintigraphy results. Liver intensity values were obtained by calculating the differences between the intensity of the liver and that of other organs in the hepatobiliary phase. Degrees of liver fibrosis were quantitatively assessed (F0-4). MRI data were correlated with the prospectively acquired clinical data. RESULTS: Varying degrees of liver fibrosis were detected in 31 of the 93 patients. The intensity ratio of the liver to spinal cord on MRI negatively correlated with hepatic fibrosis (R = -0.479, P < 0.001) and ICG-R15 (R = -0.492, P < 0.001). When patients with F0-2 (normal/moderate) and F3-4 (severe) liver fibrosis were compared, the intensity ratio of the enhanced liver to spinal cord (IRLS) on MRI was significantly lower in the F3-4 group than in the F0-2 group. IRLS was correlated with liver fibrosis, and, when an IRLS criterion of less than 1.702 was used, severe liver fibrosis could be predicted with 68.8% sensitivity and 93.5% specificity. CONCLUSION: Preoperative Gd-EOB-DTPA-enhanced MRI analysis can detect quantitative indicators of liver fibrosis and function, thus aiding the assessment of hepatic remnants prior to hepatectomy.

Successful absorption of antiretroviral drugs after gastrojejunal bypass surgery following failure of therapy through a jejunal tube.

Lopinavir, an antiretroviral drug against human immunodeficiency virus (HIV), was administered through various routes to an HIV-infected patient with duodenal malignant lymphoma. Antiretroviral drugs were first administered through a jejunal tube, and then through bypass route between the stomach and jejunum that was 20 cm distal from the ligament of Treitz after surgery. Oral administration through the bypass achieved sufficient serum concentrations of lopinavir, whereas administration through the jejunal tube did not.

Handlebar hernia: a case report.

A 36-year-old man fell from his bicycle and struck his lower abdomen on the end of the handlebar. Computed tomography (CT) showed a small bowel loop protruding into the subcutaneous fat layer of the abdominal wall. We present this case of handlebar hernia, a rare type of traumatic abdominal wall hernia, and the usefulness of CT in diagnosing such injuries.

Alterations of RB1, p53 and Wnt pathways in hepatocellular carcinomas associated with hepatitis C, hepatitis B and alcoholic liver cirrhosis.

Major etiologic factors associated with human hepatocellular carcinomas (HCCs) include infection with hepatitis C (HCV) and hepatitis B virus (HBV), excess alcohol intake and aflatoxin B(1) exposure. While the G-->T p53 mutation at codon 249 has been identified as a genetic hallmark of HCC caused by aflatoxin B(1), the genetic profile associated with other etiologic factors appears to be less distinctive. In our study, we screened HCCs resulting from HCV infection (51 cases), HBV infection (26 cases) or excess alcohol intake (23 cases) for alterations in genes involved in the RB1 pathway (p16(INK4a), p15(INK4b), RB1, CDK4 and cyclin D1), the p53 pathway (p53, p14(ARF) and MDM2) and the Wnt pathway (beta-catenin, APC). Alterations of the RB1 pathway, mainly p16(INK4a) methylation, loss of RB1 expression and cyclin D1 amplification, were most common (69-100% of cases). There was a significant correlation between loss of RB1 expression and RB1 methylation. All 24 HCCs with RB1 promoter methylation lacked RB1 expression, while none of the 67 cases with RB1 expression exhibited RB1 methylation (p < 0.0001), suggesting that promoter methylation is a major mechanism of loss of RB1 expression in HCCs. Alterations of the p53 pathway consisted mostly of p53 mutations or p14(ARF) promoter methylation (20-48%). Mutations of the p53 gene were found at a similar frequency (13-15%) in all etiologic groups, without any consistent base change or hot spot. Mutations of beta-catenin were found in 13-31% of cases, while no APC mutations were detected in any of the HCCs analyzed. With the exception of only 3 of 39 cases (8%), cyclin D1 amplification and beta-catenin mutations were mutually exclusive, supporting the view that cyclin D1 is a target of the Wnt signaling pathway. Overall, the RB1, p53 and Wnt pathways were commonly affected in HCCs of different etiology, probably reflecting common pathogenetic mechanisms, i.e., chronic liver injury and cirrhosis, but tumors associated with alcoholism had more frequent alterations in the RB1 and p53 pathways than those caused by HCV infection.