Laparoscopic liver resection of hepatocellular carcinoma located in segments 7 or 8.

BACKGROUND: Many centers consider hepatocellular carcinoma (HCC) located in segments 7 or 8 to be unsuitable for laparoscopic liver resection (LLR). We evaluated the safety of LLR of HCC in segments 7 or 8 following the introduction of new laparoscopic techniques. METHODS: This retrospective study included 104 patients who underwent LLR (n = 46) or open liver resection (OLR) (n = 58) for HCC located in segments 7 or 8 between October 2004 and June 2015. The LLR group was subdivided into two subgroups according to whether LLR was performed before (Lap1; n = 29) or after (Lap2; n = 17) the introduction of the Pringle maneuver, intercostal trocars, and semi-lateral patient positioning. RESULTS: Non-anatomical resection was more frequent (63.0 vs. 29.3%; P < 0.001) and tumor size was smaller (2.8 vs. 4.7 cm; P < 0.001) in the LLR group than in the OLR group. Blood transfusion (P = 0.526), operation time (P = 0.267), postoperative complications (P = 0.051), and resection margin (P = 0.705) were similar in both groups. LLR was associated with less blood loss (550 vs. 700 ml, P = 0.030) and shorter hospital stay (8 vs. 10 days; P = 0.001). The 3-year overall (90.2 vs. 81.2%, P = 0.096) and disease-free survival (15.1 vs. 12.1%; P = 0.857) rates were similar in both groups. The Lap2 group has less blood loss (230 vs. 500 ml; P = 0.005) and shorter hospital stay (7 vs. 9 days; P = 0.038) compared with the Lap1 group. CONCLUSION: LLR can be safely performed for HCC located in segments 7 or 8 with recent improvements in surgical techniques and accumulated experience.

Comparison of Arthroscopically Guided Suprascapular Nerve Block and Blinded Axillary Nerve Block vs. Blinded Suprascapular Nerve Block in Arthroscopic Rotator Cuff Repair: A Randomized Controlled Trial.

BACKGROUND: The purpose of this study was to compare the results of arthroscopically guided suprascapular nerve block (SSNB) and blinded axillary nerve block with those of blinded SSNB in terms of postoperative pain and satisfaction within the first 48 hours after arthroscopic rotator cuff repair. METHODS: Forty patients who underwent arthroscopic rotator cuff repair for medium-sized full thickness rotator cuff tears were included in this study. Among them, 20 patients were randomly assigned to group 1 and preemptively underwent blinded SSNB and axillary nerve block of 10 mL 0.25% ropivacaine and received arthroscopically guided SSNB with 10 mL of 0.25% ropivacaine. The other 20 patients were assigned to group 2 and received blinded SSNB with 10 mL of 0.25% ropivacaine. Visual analog scale (VAS) score for pain and patient satisfaction score were assessed 4, 8, 12, 24, 36, and 48 hours postoperatively. RESULTS: The mean VAS score for pain was significantly lower 4, 8, 12, 24, 36, and 48 hours postoperatively in group 1 (group 1 vs. group 2; 5.2 vs. 7.4, 4.1 vs. 6.1, 3.0 vs. 5.1, 2.1 vs. 4.2, 0.9 vs. 3.9, and 1.3 vs. 3.3, respectively). The mean patient satisfaction score was significantly higher at postoperative 4, 8, 12, 24, 36, and 48 hours in group 1 (group 1 vs. group 2; 6.7 vs. 3.9, 7.4 vs. 5.1, 8.8 vs. 5.9, 9.2 vs. 6.7, 9.5 vs. 6.9, and 9.0 vs. 7.2, respectively). CONCLUSIONS: Arthroscopically guided SSNB and blinded axillary nerve block in arthroscopic rotator cuff repair for medium-sized rotator cuff tears provided more improvement in VAS for pain and greater patient satisfaction in the first 48 postoperative hours than blinded SSNB.

Prediction of surgical outcomes of laparoscopic liver resections for hepatocellular carcinoma by defining surgical difficulty.

BACKGROUND: Several classification systems for assessing the surgical difficulty of laparoscopic liver resection (LLR) have been proposed. We evaluated three current classification systems, including traditional Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System for predicting the surgical outcomes after LLR. METHODS: We reviewed the clinical data of 301 patients who underwent LLR for hepatocellular carcinoma between March 1, 2004 and June 30, 2015. We compared the intraoperative, pathologic, and postoperative outcomes according to the three classifications. We also compared the prognostic value of the three classifications using receiver operating characteristic (ROC) curves. RESULTS: The Major/Minor Classification, Complexity Classification, and the Difficulty Scoring System efficiently differentiated surgical difficulty in terms of blood loss (P = 0.001, P = 0.009, and P < 0.001, respectively) and operation time (all P < 0.001). Regarding intraoperative outcomes, the Difficulty Scoring System and Complexity Classification successfully differentiated the transfusion rate (P = 0.001 and P < 0.001, respectively). However, only the Complexity Classification adequately predicted severe postoperative complications (P = 0.032), the severity of complications (P < 0.001), and the length of hospital stay (P = 0.005). In ROC curve analysis, the Complexity Classification (area under the curve [AUC] = 0.611) outperformed the Major/Minor Classification (AUC = 0.544) and the Difficulty Scoring System (AUC = 0.530) for predicting severe postoperative complications. None of the classification systems predicted recurrence or patient survival. CONCLUSION: The Complexity Classification was superior to the other methods for assessing surgical difficulty and predicting complications after LLR for hepatocellular carcinoma.

Laparoscopic Anatomical Segment 2 Segmentectomy by the Glissonian Approach.

BACKGROUND: When hepatocellular carcinoma (HCC) was located in segment 2 (S2), segment-oriented hepatectomy was more beneficial than left lateral sectionectomy as this type of anatomical resection preserved the volume of the nontumor-bearing segment. Herein, we presented 2 cases (1 with video) of laparoscopic anatomical S2 segmentectomy by the Glissonian approach. METHODS: The first patient was a 69-year-old woman, who had an incidentally detected liver nodule on abdominal ultrasound for systemic surveillance for her breast cancer. The preoperative liver function was Child-Pugh class A. Abdominal computed tomography showed a 2 cm low attenuating lesion in S2. Contrast magnetic resonance imaging (MRI) showed the same lesion with features more suggestive of HCC. In view of the inconclusive imaging findings, a needle biopsy was performed and it confirmed the diagnosis of HCC. The second patient was a 57-year-old man with hepatitis B and Child-Pugh class B liver cirrhosis. He had an enlarging nonenhancing liver nodule in S2 noted on MRI. Laparoscopic anatomical S2 segmentectomy was performed for these 2 patients. RESULTS: The operative time for the first and second patients was 240 and 185 minutes, respectively. The respective estimated intraoperative blood loss was 50 and 250 mL and no transfusion was necessary. The patients were discharged on the fourth and fifth postoperative day without any complications, respectively. CONCLUSION: This study showed the feasibility of performing a laparoscopic S2 segmentectomy by the Glissonian approach.

Association of Remnant Liver Ischemia With Early Recurrence and Poor Survival After Liver Resection in Patients With Hepatocellular Carcinoma.

Importance: The remnant liver after hepatectomy may have inadequate blood supply, especially following nonanatomical resection or vascular damage. Objective: To evaluate whether remnant liver ischemia (RLI) may have an adverse effect on long-term survival and morbidity after liver resection in patients with hepatocellular carcinoma. Design, Setting, and Participants: This study was a retrospective analysis at Seoul National University Bundang Hospital. Remnant liver ischemia was graded on postoperative computed tomographic scans in 328 patients who underwent hepatectomy for hepatocellular carcinoma between January 1, 2004, and December 31, 2013. Main Outcomes and Measures: Remnant liver ischemia was defined as reduced or absent contrast enhancement during the venous phase. Remnant liver ischemia was classified as minimal (none or marginal) or severe (partial, segmental, or necrotic). Results: Among 328 patients (252 male and 76 female; age range, 26-83 years [mean age, 58.2 years]), radiologic signs of severe RLI were found in 98 patients (29.9%), of whom 63, 16, and 19 had partial, segmental, or necrotic RLI, respectively. These patients experienced more complications and longer hospital stay than patients with minimal RLI. Preoperative history of transarterial embolization (odds ratio [OR], 1.77; 95% CI, 1.02-3.03; P = .04), use of the Pringle maneuver (OR, 1.96; 95% CI, 1.08-3.58; P = .03), and longer operative time (OR, 1.003; 95% CI, 1.002-1.005; P < .001) were independent risk factors for severe RLI. Early recurrence rates within 6 (60.2% vs 9.6%) or 12 (79.6% vs 18.7%) months after hepatectomy were higher in patients with severe RLI than in patients without RLI (P < .001). Severe remnant liver ischemia was an independent risk factor for overall survival (OR, 6.98; 95% CI, 4.27-11.43; P < .001) and disease-free survival (OR, 5.15; 95% CI, 3.62-7.35; P < .001). Conclusions and Relevance: Preventive management and technical refinements in hepatectomy are important to decrease the risk of RLI and to improve survival of patients with hepatocellular carcinoma.

Laparoscopic Total Caudate Lobectomy for Hepatocellular Carcinoma.

BACKGROUND: Caudate lobe is located in the deep dorsal area of the liver between the portal triad and the inferior vena cava (IVC). Torrential bleeding can occur from the IVC and short hepatic veins during dissection. Isolated total caudate lobe resection is still rare and technically demanding. We herein present a video on the technical aspect of laparoscopic total caudate lobectomy. METHOD: A 61-year-old woman was admitted for recurrent hepatocellular carcinoma detected on imaging. She had history of multifocal hepatocellular carcinoma in July 2015 and underwent open cholecystectomy, segment 6 and segment 8 tumorectomy. Ten months later, the computed tomography scan and magnetic resonance imaging showed a 1 cm arterial enhancing lesion in segment I (S1) with no other foci of recurrence. Laparoscopic total caudate lobectomy was contemplated. RESULTS: The operative time was 270 minutes. The intraoperative blood loss was 200 mL and blood transfusion was not necessary. The patient was discharged on the fourth postoperative day without any complications. CONCLUSION: This report showed the safety and feasibility of laparoscopic total caudate lobectomy. Nonetheless, it is a technically demanding procedure. It should be performed in carefully selected patients and by experienced hepatobiliary surgeons proficient in laparoscopic liver resection.

Regulation of Airway Inflammation by G-protein Regulatory Motif Peptides of AGS3 protein.

Respiratory diseases such as asthma, chronic obstructive pulmonary disease (COPD), and lung infections have critical consequences on mortality and morbidity in humans. The aims of the present study were to examine the mechanisms by which CXCL12 affects MUC1 transcription and airway inflammation, which depend on activator of G-protein signaling (AGS) 3 and to identify specific molecules that suppress CXCL12-induced airway inflammation by acting on G-protein-coupled receptors. Herein, AGS3 suppresses CXCL12-mediated upregulation of MUC1 and TNFα by regulating Gαi. We found that the G-protein regulatory (GPR) motif peptide in AGS3 binds to Gαi and downregulates MUC1 expression; in contrast, this motif upregulates TNFα expression. Mutated GPR Q34A peptide increased the expression of MUC1 and TGFß but decreased the expression of TNFα and IL-6. Moreover, CXCR4-induced dendritic extensions in 2D and 3D matrix cultures were inhibited by the GPR Q34A peptide compared with a wild-type GPR peptide. The GPR Q34A peptide also inhibited CXCL12-induced morphological changes and inflammatory cell infiltration in the mouse lung, and production of inflammatory cytokines in bronchoalveolar lavage (BAL) fluid and the lungs. Our data indicate that the GPR motif of AGS3 is critical for regulating MUC1/Muc1 expression and cytokine production in the inflammatory microenvironment.

Clinical Relevance of the Tumor Location-Modified Lauren Classification System of Gastric Cancer.

PURPOSE: The Lauren classification system is a very commonly used pathological classification system of gastric adenocarcinoma. A recent study proposed that the Lauren classification should be modified to include the anatomical location of the tumor. The resulting three types were found to differ significantly in terms of genomic expression profiles. This retrospective cohort study aimed to evaluate the clinical significance of the modified Lauren classification (MLC). MATERIALS AND METHODS: A total of 677 consecutive patients who underwent curative gastrectomy from January 2005 to December 2007 for histologically confirmed gastric cancer were included. The patients were divided according to the MLC into proximal non-diffuse (PND), diffuse (D), and distal non-diffuse (DND) type. The groups were compared in terms of clinical features and overall survival. Multivariate analysis served to assess the association between MLC and prognosis. RESULTS: Of the 677 patients, 48, 358, and 271 had PND, D, and DND, respectively. Their 5-year overall survival rates were 77.1%, 77.7%, and 90.4%. Compared to D and PND, DND was associated with significantly better overall survival (both P<0.01). Multivariate analysis showed that age, differentiation, lympho-vascular invasion, T and N stage, but not MLC, were independent prognostic factors for overall survival. Multivariate analysis of early gastric cancer patients showed that MLC was an independent prognostic factor for overall survival (odds ratio, 5.946; 95% confidence intervals, 1.524~23.197; P=0.010). CONCLUSIONS: MLC is prognostic for survival in patients with gastric adenocarcinoma, in early gastric cancer. DND was associated with an improved prognosis compared to PND or D.

Silencing of MUC8 by siRNA increases P2Y2-induced airway inflammation.

Mucin hypersecretion and overproduction are frequent manifestations of respiratory disease. Determining the physiological function of airway mucin is presently considered more important than identifying the relevant signaling pathways. The lack of a full-length human mucin 8 (MUC8) cDNA sequence has hindered the generation of a Muc8 knockout mouse line. Thus, the precise physiological functions of MUC8 are unclear. Herein, we investigated the function of MUC8 using a small-interfering RNA (siRNA)-mediated genetic silencing approach in human airway epithelial cells. Herein, intracellular IL-1α production was stimulated by an ATP/P2Y2 complex. While ATP/P2Y2 increased IL-1α secretion in a time-dependent manner, treatment with P2Y2-specific siRNA significantly decreased IL-1α secretion. Moreover, ATP increased P2Y2-mediated upregulation of MUC8 expression; however, IL-1α significantly decreased the extent to which ATP/P2Y2 upregulated MUC8 expression. Interestingly, treatment with MUC8-specific siRNA decreased the production of anti-inflammatory cytokines (TGF-ß and IL-1 receptor antagonist) and increased the production of inflammatory cytokines (IL-1α and IL-6) in our system. In addition, siRNA-mediated knockdown of MUC8 expression dramatically increased the secretion of inflammatory chemokines and resulted in an approximately threefold decrease in cell chemotaxis. We propose that MUC8 may function as an anti-inflammatory mucin that participates in inflammatory response by attracting immune cells/cytokines to the site of inflammation. Our results provide new insight into the physiological function of MUC8 and enhance our understanding of mucin overproduction during airway inflammation.

Peptidoglycan from Staphylococcus aureus increases MUC5AC gene expression via RSK1-CREB pathway in human airway epithelial cells.

Respiratory tract exposure to viruses, air pollutants, or bacterial pathogens can lead to pulmonary diseases. The molecular mechanism of mucous overproduction increased by these pathogens provides the knowledge for developing new therapeutic strategies. There is established in vitro data demonstrating that the overexpression of MUC5AC is induced by peptidoglycan (PGN) derived from Staphylococcus aureus. However, the mechanisms by which PGN activates MUC5AC gene expression in the airway remain unclear. The aim of this study was to identify the mechanism of PGN-induced MUC5AC gene expression. We found that PGN could induce MUC5AC gene expressions in a time- and dose-dependent manner. Moreover, activations of ERK1/2 and JNK increased after treatment of cells with PGN, whereas phosporylation of p38 was undetected. Of these MAPKs, pharmacologic inhibition of ERK1/2 decreased PGN-induced MUC5AC gene expression. In addition, we checked the activation of p90 ribosomal S6 kinase 1 (RSK1) as a downstream signaling target of ERK1/2 in PGN signaling. The activation of RSK1 was prevented by pretreatment with PD98059. We also found that RSK1 mediated the PGN-induced phosphorylation of cAMP response element-binding protein (CREB) and the transcription of MUC5AC. Furthermore, the cAMP-response element (CRE) in the MUC5AC promoter appears to be important for PGN-induced MUC5AC gene expression in NCI-H292 cells.

Cardiovascular responses to head-out water immersion in Korean women breath-hold divers.

Head-out water immersion (HOI) increases cardiac output (CO) for a given oxygen consumption. To investigate whether professional breath-hold divers show a similar response, cardiovascular responses to HOI were compared between six Korean women breath-hold divers, six non-diving housewives and six non-diving young women at rest and while performing leg cycle exercise of moderate intensity (Deltametabolic rate = approximately 100 W m(-2)) in water at a thermoneutral temperature (34.5 degrees C). In all three groups, HOI increased CO markedly due to a rise in stroke volume, with no significant change in heart rate (HR) and arterial blood pressure (BP). Thus, total peripheral resistance (TPR) and arterio-venous oxygen content difference fell significantly. During dynamic exercise in water CO increased mainly due to a rise in HR. The arterial systolic BP rose slightly with no significant change in diastolic BP, and the TPR fell 20-40% with similar responses among the three groups of subjects. This study showed that both at rest and during exercise, cardiovascular responses to immersion do not vary significantly with age and water immersion experience.

Effect of uniform and non-uniform skin temperature on thermal exchanges in water in humans.

We investigated the effect of uniform (UST) and non-uniform (NUST) skin temperature on thermal exchanges during a 3-h water immersion in five male subjects wearing (NUST) or not wearing (UST) a water-perfused garment. UST was achieved by immersing the nude subject in water up to the neck. For each subject, the water temperature was adjusted to the critical temperature ( T(cw), 31.4 +/- 0.9 degrees C) or 3 degrees C below T(cw) ( T(cw) - 3). NUST was achieved by perfusing different segments of the perfused garment with water of different temperatures. The water temperature of the segment was independently adjusted according to the skin temperature distribution in cold air, the mean skin temperature being the same as the UST. At T(cw) and T(cw) - 3, changes in esophageal and mean skin temperatures were identical in UST and NUST conditions, but the skin temperature of the trunk was higher and that of the limb was lower in the NUST condition. Heat production and the overall skin heat flux at T(cw) were identical in the two conditions, but those at T(cw) - 3 were about 25% lower ( P < 0.05) in NUST than in UST conditions. At T(cw) - 3, the overall tissue insulation was 36% higher ( P < 0.05) in NUST than in UST conditions, mainly because of higher limb insulation. Thermogenesis due to shivering was lower by 62% ( P < 0.05) in NUST than in UST. We conclude that the NUST condition increased tissue insulation and suppressed shivering. This suggests that a high skin temperature of the trunk attenuates shivering in cold water and increases the ability to defend body temperature more economically in cold water.