Predictors of a difficult Pringle maneuver in laparoscopic liver resection and evaluation of alternative procedures to assist bleeding control.

PURPOSE: To evaluate the predictors of a difficult Pringle maneuver (PM) in laparoscopic liver resection (LLR) and to assess alternative procedures to PM. METHODS: Data from patients undergoing LLR between 2013 and 2020 were reviewed retrospectively. Univariate and multivariate analyses were performed and the outcomes of patients who underwent PM or alternative procedures were compared. RESULTS: Among 106 patients who underwent LLR, PM could not be performed in 18 (17.0%) because of abdominal adhesions in 14 (77.8%) and/or collateral flow around the hepatoduodenal ligament in 5 (27.8%). Multivariate analysis revealed that Child-Pugh classification B (p = 0.034) and previous liver resection (p < 0.001) were independently associated with difficulty in performing PM in LLR. We evaluated pre-coagulation of liver tissue using microwave tissue coagulators, saline irrigation monopolar, clamping of the hepatoduodenal ligament using an intestinal clip, and hand-assisted laparoscopic surgery as alternatives procedures to PM. There were no significant differences in blood loss (p = 0.391) or transfusion (p = 0.518) between the PM and alternative procedures. CONCLUSIONS: Child-Pugh classification B and previous liver resection were identified as predictors of a difficult PM in LLR. The alternative procedures were found to be effective.

Serum p53 antibody as a potential tumor marker in extrahepatic cholangiocarcinoma.

PURPOSE: Only a few studies have evaluated the clinicopathological significance of the p53 protein expression and s-p53-Abs level in patients with cholangiocarcinoma. We therefore analyzed the clinicopathological and prognostic significance of s-p53-Abs in patients with extrahepatic cholangiocarcinoma. METHODS: We prospectively evaluated s-p53-Abs levels before and after surgery in 61 patients with extrahepatic cholangiocarcinoma to determine the relationship between clinicopathological factors and the prognostic significance of s-p53-Abs. RESULTS: Among a total of 61 primary extrahepatic cholangiocarcinoma cases, 23% were positive for s-p53-Abs. Combination of s-p53-Abs with the conventional serum markers carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) significantly increased the rate of positive extrahepatic cholangiocarcinoma cases (57% for CEA and/or CA19-9 vs. 75% for CEA and/or CA19-9 and/or s-p53-Abs, P = 0.035). There were no significant differences in clinicopathological factors between the p53-seropositive and p53-seronegative patients. An immunohistochemical analysis showed the presence of significant associations between the intensity (P = 0.003) and extent (P = 0.001) of p53 immunoreactivity and p53-seropositivitly. Although s-p53-Abs was not a significant prognostic factor for the survival in either univariate or multivariate analyses, p53 immunoreactivity was independently associated with a poor survival. Among patients positive for s-p53-Abs before surgery, the s-p53-Abs levels were reduced after surgery in most. CONCLUSION: These findings suggested that s-p53-Abs might be associated with p53 immunoreactivity. In addition, s-p53-Abs may be useful for a diagnosis, but was not useful for predicting tumor recurrence or the survival. This study was registered as UMIN000014530.

Evolution and revolution of laparoscopic liver resection in Japan.

Due to important technological developments and improved endoscopic techniques, laparoscopic liver resection (LLR) is now considered the approach of choice and is increasingly performed worldwide. Recent systematic reviews and meta-analyses of observational data reported that LLR was associated with less bleeding, fewer complications, and no oncological disadvantage; however, no prospective randomized trials have been conducted. LLR will continue to evolve as a surgical approach that improves patient's quality of life. LLR will not totally supplant open liver surgery, and major LLR remains to be technically challenging procedure. The success of LLR depends on individual learning curves and adherence to surgical indications. A recent study proposed a scoring system for stepwise application of LLR, which was based on experience at high-volume Japanese centers. A cluster of deaths after major LLR was sensationally reported by the Japanese media in 2014. In response, the Japanese Society of Hepato-Biliary-Pancreatic Surgery conducted emergency data collection on operative mortality. The results demonstrated that mortality was not higher than that for open procedures except for hemi-hepatectomy with biliary reconstruction. An online prospective registry system for LLR was established in 2015 to be transparent for patients who might potentially undergo treatment with this newly developed, technically demanding surgical procedure.

Effects of chronic restraint-induced stress on radiation-induced chromosomal aberrations in mouse splenocytes.

Both ionizing radiation (IR) and psychological stress (PS) cause detrimental effects on humans. A recent study showed that chronic restraint-induced PS (CRIPS) diminished the functions of Trp53 and enhanced radiocarcinogenesis in Trp53-heterozygous (Trp53+/-) mice. These findings had a marked impact on the academic field as well as the general public, particularly among residents living in areas radioactively contaminated by nuclear accidents. In an attempt to elucidate the modifying effects of CRIPS on radiation-induced health consequences in Trp53 wild-type (Trp53+/+) animals, investigations involving multidisciplinary analyses were performed. We herein demonstrated that CRIPS induced changes in the frequency of IR-induced chromosomal aberrations (CAs) in splenocytes. Five-week-old male Trp53+/+ C57BL/6J mice were restrained for 6h per day for 28 consecutive days, and total body irradiation (TBI) at a dose of 4Gy was performed on the 8th day. Metaphase chromosome spreads prepared from splenocytes at the end of the 28-day restraint regimen were painted with fluorescence in situ hybridization (FISH) probes for chromosomes 1, 2, and 3. The results obtained showed that CRIPS alone did not induce CAs, while TBI caused significant increases in CAs, mostly translocations. Translocations appeared at a lower frequency in mice exposed to TBI plus CRIPS than in those exposed to TBI alone. No significant differences were observed in the frequencies of the other types of CAs (insertions, dicentrics, and fragments) visualized with FISH between these experimental groups (TBI+CRIPS vs. TBI). These results suggest that CRIPS does not appear to synergize with the clastogenicity of IR.

Estimation of absorbed radiation dose rates in wild rodents inhabiting a site severely contaminated by the Fukushima Dai-ichi nuclear power plant accident.

The dose rates of radiation absorbed by wild rodents inhabiting a site severely contaminated by the Fukushima Dai-ichi Nuclear Power Plant accident were estimated. The large Japanese field mouse (Apodemus speciosus), also called the wood mouse, was the major rodent species captured in the sampling area, although other species of rodents, such as small field mice (Apodemus argenteus) and Japanese grass voles (Microtus montebelli), were also collected. The external exposure of rodents calculated from the activity concentrations of radiocesium ((134)Cs and (137)Cs) in litter and soil samples using the ERICA (Environmental Risk from Ionizing Contaminants: Assessment and Management) tool under the assumption that radionuclides existed as the infinite plane isotropic source was almost the same as those measured directly with glass dosimeters embedded in rodent abdomens. Our findings suggest that the ERICA tool is useful for estimating external dose rates to small animals inhabiting forest floors; however, the estimated dose rates showed large standard deviations. This could be an indication of the inhomogeneous distribution of radionuclides in the sampled litter and soil. There was a 50-fold difference between minimum and maximum whole-body activity concentrations measured in rodents at the time of capture. The radionuclides retained in rodents after capture decreased exponentially over time. Regression equations indicated that the biological half-life of radiocesium after capture was 3.31 d. At the time of capture, the lowest activity concentration was measured in the lung and was approximately half of the highest concentration measured in the mixture of muscle and bone. The average internal absorbed dose rate was markedly smaller than the average external dose rate (<10% of the total absorbed dose rate). The average total absorbed dose rate to wild rodents inhabiting the sampling area was estimated to be approximately 52 µGy h(-1) (1.2 mGy d(-1)), even 3 years after the accident. This dose rate exceeds 0.1-1 mGy d(-1) derived consideration reference level for Reference rat proposed by the International Commission on Radiological Protection (ICRP).

Cytokinesis block micronucleus assay in field plants for monitoring radiation-induced genotoxicity of the environment.

Effective biomonitoring for detection of radiation-induced genotoxicity of contaminants in natural environments involves testing of field plants for cytogenetic changes. To increase the efficiency and precision of cytogenetic analyses of field plants that have naturally high individual variability, an improved micronucleus assay is proposed that employs a cytokinesis block technique similar to the lymphocyte test system used in mammals. In seed embryonic meristems of the Japanese cedar, application of a methylxanthine derivative, 3-isobutyl-1-methylxanthine (IBMX), was found to be effective in inhibiting cytokinesis to make once-divided cells easily recognizable by their binucleate appearance. In the meristem of IBMX-treated seminal roots from X-ray-irradiated seeds, variation in micronucleus frequency in the binucleate cell population was reduced compared to that in the total cell population. The highest efficiency of measurement of micronucleus frequencies was obtained in the root meristems where 0.2- to 1.5-mm-long seminal roots were incubated with IBMX for 24 h. This result indicated that this root elongation stage corresponded to the first divisions of the root meristematic cells, and was therefore suitable for obtaining reliable estimations of accumulated genetic damage in the seeds. This cytokinesis block assay applied specifically at the root elongation stage was then used to examine dose-response relationships in Japanese cedar seeds irradiated either acutely with X-rays or chronically with γ-rays. The resulting dose-response curve for the acute X-ray irradiation was fitted onto a linear-quadratic regression curve, whereas the dose-response curve for the chronic γ-irradiation matched a linear regression line better. Both dose-response curves were consistent with the target theory of classical radiation biology. The good agreement of the micronucleus data to a simple dose-response model indicates the proposed accuracy of the cytokinesis block micronucleus assay for plant monitoring.

Efficacy of laparoscopic liver resection in colorectal liver metastases and the influence of preoperative chemotherapy.

BACKGROUND: Since 1993, we have performed minimally invasive laparoscopic liver resection (LLR) to treat malignant liver cancer, including colorectal liver metastases (CLM). However, further studies are needed to accumulate sufficient evidence on the oncological outcome of LLR for CLM. METHODS: To elucidate the efficacy of LLR for CLM, this study comparatively analyzed the invasiveness and short-term prognosis of LLR (n=43 cases) and open liver resection (OR) (n=62 cases) performed for CLM after 2006 and also investigated the safety of LLR following chemotherapy. RESULTS: Compared with the OR group, the LLR group had significantly less blood loss (P<0.001) and a shorter hospital stay (P<0.001). The E-PASS scoring system was used to compare surgical invasiveness, and although the preoperative risk score did not differ between the groups, the surgical stress score and comprehensive risk score were significantly lower in the LLR group (P<0.001). Concerning the survival rate and disease-free survival rate, there were no significant differences between procedures. However, more clinical cases and longer follow-up periods are needed to reach a definitive conclusion.Preoperative hemanalysis, intraoperative bleeding, complications, and postoperative length of stay did not differ significantly between LLR patients with preoperative chemotherapy and those with surgery alone, indicating no adverse effects of chemotherapy. CONCLUSIONS: LLR can be an effective minimally invasive surgery in CLM patients receiving both perioperative chemotherapy and surgery. Because LLR is comparable with OR with regard to short-term oncological outcome, LLR may be a valuable option for CLM.

Effects of chronic γ-irradiation on growth and survival of the Tohoku hynobiid salamander, Hynobius lichenatus.

The Tohoku hynobiid salamanders, Hynobius lichenatus, were chronically irradiated with γ-rays from embryonic to juvenile stages for 450 days. At 490 µGy h(-1) or lower dose rates, growth and survival were not significantly affected by irradiation, and any morphological aberrations and histological damages were not observed. At 4600 µGy h(-1), growth was severely inhibited, and all the individuals died mostly at the juvenile stage. Chronic LD50 was 42 Gy as a total dose. In the liver, the number of hematopoietic cells was significantly reduced in the living juveniles, and these cells disappeared in the dead juveniles. In the spleen, mature lymphocytes were depleted in the living larvae, and almost all the heamtopoietic cells disappeared in the dead juveniles. These results suggest that this salamander died due to acute radiation syndrome, i.e., hematopoietic damage and subsequent sepsis caused by immune depression. The death would be also attributed to skin damage inducing infection. At 18,000 µGy h(-1), morphological aberrations and severe growth inhibition were observed. All the individuals died at the larval stage due to a multiple organ failure. Chronic LD50 was 28 Gy as a total dose. Assuming that chronic LD50 was 42 Gy at lower dose rates than 4600 µGy h(-1), a chronic median lethal dose rate could be estimated to be <340 µGy h(-1) for the whole life (>14 years). These results suggest that, among guidance dose rates, i.e., 4-400 µGy h(-1), proposed by various organisations and research programmes for protection of amphibians and taxonomic groups or ecosystems including amphibians, most of them would protect this salamander but the highest value may not on the whole life scale.

UBE4B protein couples ubiquitination and sorting machineries to enable epidermal growth factor receptor (EGFR) degradation.

The signaling of plasma membrane proteins is tuned by internalization and sorting in the endocytic pathway prior to recycling or degradation in lysosomes. Ubiquitin modification allows recognition and association of cargo with endosomally associated protein complexes, enabling sorting of proteins to be degraded from those to be recycled. The mechanism that provides coordination between the cellular machineries that mediate ubiquitination and endosomal sorting is unknown. We report that the ubiquitin ligase UBE4B is recruited to endosomes in response to epidermal growth factor receptor (EGFR) activation by binding to Hrs, a key component of endosomal sorting complex required for transport (ESCRT) 0. We identify the EGFR as a substrate for UBE4B, establish UBE4B as a regulator of EGFR degradation, and describe a mechanism by which UBE4B regulates endosomal sorting, affecting cellular levels of the EGFR and its downstream signaling. We propose a model in which the coordinated action of UBE4B, ESCRT-0, and the deubiquitinating enzyme USP8 enable the endosomal sorting and lysosomal degradation of the EGFR.

[A case of pancreatic cancer with distant metastasis successfully resected after neoadjuvant chemotherapy with a combination of S-1 and gemcitabine].

The patient was a 70-year-old man with a chief complaint of cough.After careful examination, he was diagnosed with pancreatic body cancer with metastasis to the liver and right pleura and with early gastric cancer.He was treated with S-1 and gemcitabine combination chemotherapy.After completing 3 courses, the distant metastasis could no longer be observed. After completing 4 courses, the tumor marker level in the serum was normalized.The pancreatic lesion was restricted by the end of 10 courses, and the pancreas body and tail were resected.After additional chemotherapy with S-1, he was switched to weekly paclitaxel therapy because of peritoneal dissemination.The patient survived for 15 months after surgery.In cases of unresectable pancreatic cancer with distant metastasis, it may be possible to consider the surgical option when chemotherapy is effective.

[An analysis of cases with malignant pyloroduodenal obstruction from unresectable pancreatic cancer who underwent palliative gastrojejunostomy].

The aims of this study were to examine the effectiveness of palliative gastrojejunostomy in terms of the postoperative food intake and hospital stay in patients with advanced pancreatic cancer. Retrospective data from 17 consecutive patients who underwent gastrojejunostomy from 2008 to 2013 in Toho University Omori Medical Center were analyzed. In our analysis, patients without peritoneal dissemination and distant metastasis were associated with poor oral intake and patients with lower neutrophil to lymphocyte ratio (NLR) were associated with rate of discharge.

Dose-rate effect was observed in T98G glioma cells following BNCT.

BACKGROUND: It is generally said that low LET radiation produce high dose-rate effect, on the other hand, no significant dose rate effect is observed in high LET radiation. Although high LET radiations are produced in BNCT, little is known about dose-rate effect of BNCT. MATERIALS AND METHODS: T98G cells, which were tumor cells, were irradiated by neutron mixed beam with BPA. As normal tissue derived cells, Chinese hamster ovary (CHO-K1) cells and DNA double strand breaks (DNA-DSBs) repair deficient cells, xrs5 cells were irradiated by the neutrons (not including BPA). To DNA-DSBs analysis, T98G cells were stained immunochemically with 53BP1 antibody. The number of DNA-DSBs was determined by counting 53BP1 foci. RESULTS: There was no dose-rate effect in xrs5 cells. D0 difference between 4cGy/min and 20cGy/min irradiation were 0.5 and 5.9 at the neutron and gamma-ray irradiation for CHO-K1, and 0.3 at the neutron for T98G cells. D0 difference between 20cGy/min and 80cGy/min irradiation for T98G cells were 1.2 and 0.6 at neutron irradiation plus BPA and gamma-ray. The differences between neutron irradiations at the dose rate in T98G cells were supported by not only the cell viability but also 53BP1 foci assay at 24h following irradiation to monitor DNA-DSBs. CONCLUSION: Dose-rate effect of BNCT when T98G cells include 20ppm BPA was greater than that of gamma-ray irradiation. Moreover, Dose-rate effect of the neutron beam when CHO-K1 cells did not include BPA was less than that of gamma-ray irradiation These present results may suggest the importance of dose-rate effect for more efficient BNCT and the side effect reduction.

Effectiveness of laparoscopic subtotal cholecystectomy: perioperative and long-term postoperative results.

BACKGROUND/AIMS: We analyzed perioperative and long-term postoperative data to determine the effectiveness of laparoscopic subtotal cholecystectomy (LSC). METHODOLOGY: 89 LSCs done at our center were classified into 3 groups according to the operative procedure required to treat severe cholecystitis. Perioperative and long-term postoperative results were then compared with standard laparoscopic cholecystectomy (s-LC). RESULTS: Operative time was longer and postoperative CRP level was higher for LSC. Significantly more bleeding and longer operative times were seen only in the LSC-II subgroup, and average postoperative hospital stay was longer only in the LSC-III subgroup. As for long-term (1.5 to 8 years) postoperative results, 3 of 26 LSC-III cases had a relapse of cholecystolithiasis in remnant gallbladder tissue 2 years or later after initial surgery. CONCLUSIONS: There were no serious intraoperative complications such as the bile duct injury, and a smaller proportion of procedures were intraoperatively converted to open laparotomy. It is considered that LSC is a safe, useful surgical procedure to the patients in whom the neck of the gallbladder is anatomically unclear due to cholecystitis or fibrosis although patients undergoing LSC-III should be monitored for cholecystolithiasis in remnant gallbladder tissue. LSC is often the procedure of choice for patients.

Relative biological effects of neutron mixed-beam irradiation for boron neutron capture therapy on cell survival and DNA double-strand breaks in cultured mammalian cells.

Understanding the biological effects of neutron mixed-beam irradiation used for boron neutron capture therapy (BNCT) is important in order to improve the efficacy of the therapy and to reduce side effects. In the present study, cell viability and DNA double-strand breaks (DNA-DSBs) were examined in Chinese hamster ovary cells (CHO-K1) and their radiosensitive mutant cells (xrs5, Ku80-deficient), following neutron mixed-beam irradiation for BNCT. Cell viability was significantly impaired in the neutron irradiation groups compared to the reference gamma-ray irradiation group. The relative biological effectiveness for 10% cell survival was 3.3 and 1.2 for CHO-K1 and xrs5 cells, respectively. There were a similar number of 53BP1 foci, indicators of DNA-DSBs, in the neutron mixed-beam and the gamma-ray groups. In addition, the size of the foci did not differ between groups. However, neutron mixed-beam irradiation resulted in foci with different spatial distributions. The foci were more proximal to each other in the neutron mixed-beam groups than the gamma-ray irradiation groups. These findings suggest that neutron beams may induce another type of DNA damage, such as clustered DNA-DSBs, as has been indicated for other high-LET irradiation.

Gas embolism in laparoscopic hepatectomy: what is the optimal pneumoperitoneal pressure for laparoscopic major hepatectomy?

Laparoscopic hepatectomy (LH) has become popular as a surgical treatment for liver diseases, and numerous recent studies indicate that it is safe and has advantages in selected patients. Because of the magnified view offered by the laparoscope under pneumoperitoneal pressure, LH results in less bleeding than open laparotomy. However, gas embolism is an important concern that has been discussed in the literature, and experimental studies have shown that LH is associated with a high incidence of gas embolism. Major hepatectomies are done laparoscopically in some centers, even though the risk of gas embolism is believed to be higher than for minor hepatectomy due to the wide transection plane with dissection of major hepatic veins and long operative time. At many high-volume centers, LH is performed at a pneumoperitoneal pressure less than 12 mmHg, and reports indicate that the rate of clinically severe gas embolism is low. However, more studies will be necessary to elucidate the optimal pneumoperitoneal pressure and the incidence of gas embolism during LH.

[Laparoscopic surgery for pancreatic cancer].

Laparoscopic distal pancreatectomy is currently in widespread use because of its technical simplicity, although laparoscopic pancreaticoduodenectomy is practiced in only a limited number of surgical institutions due to the associated technical difficulties especially at reconstruction. The indication for the treatment of pancreatic cancer by a laparoscopic procedure remains controversial. Because pancreatic cancer is already advanced at the time of diagnosis in many cases, it requires a difficult radical operation in terms of lymphadenectomy with nerves plexus in laparoscopic surgery. The oncologic clearance of pancreatic resection may be achievable by laparoscopic surgery, although longer follow-up and larger series of treatment are still needed.

Isotopic evidence of plutonium release into the environment from the Fukushima DNPP accident.

The Fukushima Daiichi nuclear power plant (DNPP) accident caused massive releases of radioactivity into the environment. The released highly volatile fission products, such as (129m)Te, (131)I, (134)Cs, (136)Cs and (137)Cs were found to be widely distributed in Fukushima and its adjacent prefectures in eastern Japan. However, the release of non-volatile actinides, in particular, Pu isotopes remains uncertain almost one year after the accident. Here we report the isotopic evidence for the release of Pu into the atmosphere and deposition on the ground in northwest and south of the Fukushima DNPP in the 20-30 km zones. The high activity ratio of (241)Pu/(239+240)Pu (> 100) from the Fukushima DNPP accident highlights the need for long-term (241)Pu dose assessment, and the ingrowth of (241)Am. The results are important for the estimation of reactor damage and have significant implication in the strategy of decontamination.

Derivation of hazardous doses for amphibians acutely exposed to ionising radiation.

Derivation of effect benchmark values for each taxonomic group, which has been difficult due to lack of experimental effects data, is required for more adequate protection of the environment from ionising radiation. Estimation of effects doses from nuclear DNA mass and subsequent species sensitivity distribution (SSD) analysis were proposed as a method for such a derivation in acute irradiation situations for assumed nuclear accident scenarios. As a case study, 5% hazardous doses (HD5s), at which only 5% of species are acutely affected at 50% or higher lethality, were estimated on a global scale. After nuclear DNA mass data were obtained from a database, 50% lethal doses (LD50s) for 4.8 and 36% of the global Anura and Caudata species, respectively, were estimated by correlative equations between nuclear DNA mass and LD50s. Differences between estimated and experimental LD50s were within a factor of three. The HD5s obtained by the SSD analysis of these estimated LD50s data were 5.0 and 3.1 Gy for Anura and Caudata, respectively. This approach was also applied to the derivation of regional HD5s. The respective HD5s were 6.5 and 3.2 Gy for Anura and Caudata inhabiting Japan. This HD5 value for the Japanese Anura was significantly higher than the global value, while Caudata had no significant difference in global and Japanese HD5s. These results suggest that this approach is also useful for derivation of regional benchmark values, some of which are likely different from the global values.

Environmental protection: researches in National Institute of Radiological Sciences.

Some studies for radiological protection of the environment have been made at the National Institute of Radiological Sciences (NIRS). Transfer of radionuclides and related elements has been investigated for dose estimation of non-human biota. A parameter database and radionuclide transfer models have been also developed for the Japanese environments. Dose (rate)-effect relationships for survival, growth and reproduction have been investigated in conifers, Arabidopsis, fungi, earthworms, springtails, algae, duckweeds, daphnia and medaka. Also genome-wide gene expression analysis has been carried out by high coverage expression profiling (HiCEP). Effects on aquatic microbial communities have been studied in experimental ecosystem models, i.e., microcosms. Some effects were detected at a dose rate of 1 Gy day(-1) and were likely to arise from interspecies interactions. The results obtained at NIRS have been used in development of frameworks for environmental protection by some international bodies, and will contribute to environmental protection in Japan and other Asian countries.