[A case of splenic injury after colonoscopy].

An 81-year-old woman lost consciousness and was taken to our hospital 3 days after colonoscopy was performed as a follow-up of endoscopic mucosal resection done 1 year ago for early sigmoid colon cancer detection. She had left hypochondrial pain. Based on abdominal contrast-enhanced computed tomography (CT) findings, she was diagnosed with abdominal bleeding due to injury to the lower splenic pole, and an urgent splenectomy was performed. In this case, there was no abdominal trauma to cause splenic injury. Injury to the lower splenic pole during colonoscopy was considered due to the adhesion found in the abdominal cavity. It is possible that the hemorrhage did not stop because she was taking antiplatelet drugs.

Colocutaneous fistula associated with Crohn's disease following Kugel patch repair for inguinal hernia: a case report.

Colocutaneous fistula associated with Crohn's disease after mesh repair for inguinal hernia has not been previously reported in the literature. We report such case in an 83-year-old man following a preperitoneal repair of a left-sided inguinal hernia using Kugel patch. The patient has Crohn's disease in remission status for 4 years. One month after inguinal hernia repair, he presented with fever and left-sided inguinal pain and swelling. Computed tomography revealed abscess formation in the preperitoneal and subcutaneous space of the left-sided inguinal region. Colonoscopy showed local exacerbation of Crohn's disease in the sigmoid colon, and formation of fistula between the sigmoid colon and abdominal wall of the left-sided inguinal region. We performed mesh removal with Hartmann resection following percutaneous abscess drainage. The post-operative course was uneventful, and no sign of recurrence of the hernia was found for 3 years post-operatively.

Preventive Effect of High-Dose Digestive Enzyme Management on Development of Nonalcoholic Fatty Liver Disease after Pancreaticoduodenectomy: A Randomized Controlled Clinical Trial.

BACKGROUND: Nonalcoholic fatty liver disease (NAFLD) is a complication of pancreaticoduodenectomy (PD). We conducted a randomized clinical trial to determine if high-dose digestive enzymes prevented the development of NAFLD after PD. STUDY DESIGN: This parallel-group, nonblinded, multicenter study enrolled patients undergoing elective PD at Shinshu University School of Medicine, from June 2011 to April 2017. Patients were randomly assigned to receive normal-dose (Excelase: 3.0 g/day [Meiji Seika Pharma Holdings Co, Ltd]) or high-dose digestive enzyme treatment (Excelase: 3.0 g/day; Pancreatin [Tokyo Chemical Industry Co Ltd]: 3.0 g/day; Berizym [Kyowa Pharmaceutical Industry Co Ltd]: 3.0 g/day; and Toughmac-E [Ono Pharmaceutical Co, Ltd]: 3.0 g/day) within 1 week after surgery. Because patients in the control group switched interventions upon receiving a diagnosis of NAFLD, intention-to-treat analysis was used. The primary endpoint was incidence of NAFLD within 1 year, and the secondary endpoints were the incidences of NAFLD at 1, 3, 6, and 12 months and the rate of improvement in NAFLD with high-dose transfer in the control group. The secondary analysis comprised assessment of risk factors for the development of NAFLD. RESULTS: Eighty-four patients were randomly assigned (42 per group), 80 of whom were finally analyzed (39 normal-dose, 41 high-dose). The incidence of NAFLD was significantly lower in the high-dose (8 of 41) compared with the normal-dose (25 of 39) patients (p < 0.001). Multivariate analysis identified normal-dose (odds ratio [OR] 14.65, p < 0.001), total protein ≤ 6.5g/dL (OR 9.01, p = 0.018), pre-albumin ≤ 22.0 mg/dL (OR 7.71, p = 0.018), and pancreatic function diagnostic test ≤ 70% (OR 6.66, p = 0.009) as independent risk factors. There were no adverse effects. The model was accurate (c-index = 0.92) and reliable (Hosmer-Lemeshow test p = 0.32). CONCLUSIONS: High-dose administration of digestive enzymes significantly reduced the onset of NAFLD after PD compared with normal-dose administration. Registration number: UMIN000005595 (http://www.umin.ac.jp/ctr/).

Impact of age on groin hernia profiles observed during laparoscopic transabdominal preperitoneal hernia repair.

BACKGROUND: How increasing age affects the characteristics of groin hernia remains uncertain. This study evaluated the association between age and the type of groin hernia, especially with respect to its multiplicity, observed during laparoscopic transabdominal preperitoneal (TAPP) hernia repair. METHODS: We retrospectively evaluated 634 consecutive patients with primary groin hernia who underwent laparoscopic TAPP repair between October 2000 and June 2017. Patients were stratified into 4 age groups: < 60 years, 60-69 years, 70-79 years, and 80 years or older. RESULTS: The incidence of occult contralateral hernia and multiple ipsilateral hernias increased significantly with each increasing age group: 7.3%, 10.4%, 12.7%, and 20.8% for occult contralateral hernia (p = 0.005), and 5.6%, 9.2%, 16.8%, and 21.7% for multiple ipsilateral hernias (p < 0.001), respectively. Univariate analyses showed that an older age (age ≥ 70 years) was the only factor significantly associated with the presence of multiple groin hernias (odds ratio, 2.69; 95% confidence interval, 1.89-3.81; p < 0.001). In patients with multiple ipsilateral hernias, the prevalent form in men was a pantaloons hernia, with an incidence of about 70% across all age groups, whereas in women it was groin hernias, with one component being a femoral hernia, an obturator hernia, or both. CONCLUSIONS: The multiple occurrence of groin hernias, either unilaterally or bilaterally, was a clinical feature in the elderly.

Treatment with specific soluble factors promotes the functional maturation of transcription factor-mediated, pancreatic transdifferentiated cells.

Pancreatic lineage-specific transcription factors (TFs) display instructive roles in converting adult cells to endocrine pancreatic cells through a process known as transdifferentiation. However, little is known about potential factors capable of accelerating transdifferentiation following transduction to achieve the functional maturation of transdifferentiated cells. In this study, we demonstrated, using adult liver-derived progenitor cells, that soluble factors utilized in pancreatic differentiation protocols of pluripotent stem cells promote functional maturation of TFs-mediated transdifferentiated cells. Treatment with an N2 supplement in combination with three soluble factors (glucagon-like peptide-1 [GLP-1] receptor agonist, notch inhibitor, and transforming growth factor-ß [TGF-ß] inhibitor) enhanced liver-to-pancreas transdifferentiation based on the following findings: i) the incidence of c-peptide-positive cells increased by approximately 1.2-fold after the aforementioned treatment; ii) the c-peptide expression level in the treated cells increased by approximately 12-fold as compared with the level in the untreated cells; iii) the treated cells secreted insulin in a glucose-dependent manner, whereas the untreated cells did not; and iv) transplantation of treated-transdifferentiated cells into streptozotocin-induced immunodeficient diabetic mice led to the amelioration of hyperglycemia. These results suggest that treatment with specific soluble factors promotes the functional maturation of transdifferentiated cells. Our findings could facilitate the development of new modalities for cell-replacement therapy for patients with diabetes.

Survival pathway of cholangiocarcinoma via AKT/mTOR signaling to escape RAF/MEK/ERK pathway inhibition by sorafenib.

Cholangiocarcinoma (CCC) is a strongly aggressive malignancy for which surgical resection is the only potential curative therapy. Sorafenib, a multikinase inhibitor of the RAF/MEK/ERK pathway, is a molecular-targeted drug that is approved for hepatocellular carcinoma (HCC) but not for CCC. The differences in signaling pathway characteristics under sorafenib treatment between HCC (HLF, Huh7, PLC/PRF/5) and CCC (RBE, YSCCC, Huh28) cell lines were therefore investigated using cell proliferation, western blotting, and apoptosis analyses. Sorafenib inhibited cell growth significantly less in CCC cells than in HCC cells, with lower suppression of ERK phosphorylation. Significantly decreased AKT Ser473 phosphorylation in HCC cells, and conversely enhanced phosphorylation of AKT Ser473 and mTORC2 in CCC cells, were observed with sorafenib treatment. Disassembly of the mTORC2 complex in RBE cells with siRNA targeting Rictor resulted in the downregulation of AKT Ser473 phosphorylation and enhanced apoptosis presumably via increased FOXO1, which consequently suppressed RBE cell proliferation. Phosphorylation of mTORC1 and autophagy were not influenced by sorafenib in CCC cells. Simultaneous administration of everolimus to suppress activated mTORC1 in RBE cells revealed that combined everolimus and sorafenib treatment under mTORC2 disassembly could enhance growth inhibition through the suppression of both sorafenib- and everolimus-dependent AKT Ser473 phosphorylation in addition to the inhibition of mTORC1 phosphorylation. Prevention of escape by AKT/mTOR signaling from the RAF/MEK/ERK pathway in sorafenib treatment by suppressing mTORC2 activity may lead to promising new approaches in CCC therapy.

Survival Benefits of Surgical Resection in Patients with Recurrent Biliary Tract Carcinoma.

BACKGROUND: Whether surgical resection for recurrent biliary tract carcinoma (BTC) prolongs survival and the patients who are most likely to benefit from such treatment remain unclear. METHODS: Among 251 patients with recurrences after the initial resection of BTC, a total of 21 patients (8.4%) underwent surgical resection for the recurrence, with a zero mortality rate. The clinicopathological features of these patients were compared with those of patients who did not undergo surgery. RESULTS: The median survival time (MST) after the first recurrence and the 5-year post-recurrent survival (PRS) rate were 19.8 months and 32.8%, respectively, for patients who underwent re-resection. Fourteen patients (66.7%) experienced second recurrences; however, none of these patients underwent further surgical resection. Surgical resection for recurrence was identified as an independent prognostic factor for survival after recurrence (hazard ratio of 0.33, 95% CI of 0.17-0.58, p < 0.001). Patients with less than three liver metastases had a significantly better PRS after surgical resection than after chemotherapy (p = 0.015). Among the patients with an isolated solitary liver metastasis, patients who underwent resection had a significantly longer MST after the first recurrence than patients receiving chemotherapy (22.8 vs. 10.9 months, p = 0.025), whereas the PRS was similar between the two groups among patients with two liver lesions. CONCLUSIONS: Surgical resection for recurrent BTC may prolong survival in highly selected patients. A hepatectomy might offer a survival benefit for patients with a solitary liver metastasis.

Nomogram predicting long-term survival after the diagnosis of intrahepatic recurrence of hepatocellular carcinoma following an initial liver resection.

BACKGROUND: The aim of this study was to construct and validate a nomogram for predicting survival after the intrahepatic recurrence of hepatocellular carcinoma (HCC) following an initial hepatectomy. METHODS: A primary cohort of 268 patients who underwent curative hepatectomy for HCC at Shinshu University Hospital between 1990 and 2010 was retrospectively studied. A nomogram was constructed based on independent prognostic factors for overall survival after recurrence. The predictive performance was evaluated using the concordance index (c-index) and a calibration curve. The nomogram was then externally validated in a cohort of patients from Tokyo University Hospital (n = 296). RESULTS: In multivariate analysis, the following 5 variables were identified as independent predictors of overall survival and incorporated into the nomogram-Japan Integrated Stage score at initial liver resection, platelet count at initial liver resection, time until intrahepatic recurrence, vascular invasion at recurrence, and type of treatment used for intrahepatic recurrence. The nomogram had a c-index of 0.75 (95% confidence interval 0.60-0.85) for the Shinshu cohort and 0.71 (0.57-0.81) for the Tokyo cohort. The predicted 3- and 5-year survival probabilities corresponded well with the actual outcomes. CONCLUSIONS: The established nomogram might be useful for estimating survival after the intrahepatic recurrence of HCC.

Correlation between the serum levels of type IV collagen 7s domain and the risk of intractable ascites following liver resection for hepatocellular carcinoma: A propensity score-matched analysis.

BACKGROUND: The severity of liver fibrosis has been reported to be correlated with the risk of intractable ascites after hepatectomy for hepatocellular carcinoma. Since 2009, we have measured routinely the serum concentrations of type IV collagen 7s domain (7s collagen), a biochemical marker of liver fibrosis and applied limited resection to patients with elevation of the serum 7s collagen concentrations above the upper limit of normal (6.0 ng/mL). The aim of this study was to assess the potential benefits of our treatment strategy on the postoperative outcomes of patients with hepatocellular carcinoma. METHODS: A propensity score-matched analysis was performed to compare the outcomes between patients who underwent initial hepatectomy for hepatocellular carcinoma before or after 2009 (2009 to April 2015; period 2) and those who underwent the operation prior to 2009 (1990-2008; period 1; n = 129 in each period). RESULTS: The incidence of intractable ascites was significantly lower in period 2 than in period 1 (2.3 vs 14.7%; P < .001), although the other short-term and long-term outcomes were comparable between the 2 groups. A multivariate analysis identified elevation of the serum 7s collagen concentrations to ≥7.4 ng/mL as an independent predictor of IA (odds ratio 14.1, 95% confidence interval 2.8 to 106.7; P = .001), with the area under the receiver-operating characteristic curve of 0.820 (0.648-0.919, P = .005). CONCLUSION: Modification of the surgical procedure according to the serum 7s collagen concentration is beneficial for reducing the risk of development of intractable ascites after hepatectomy for hepatocellular carcinoma.

Contrast-enhancement ratio on multiphase enhanced computed tomography predicts recurrence of pancreatic neuroendocrine tumor after curative resection.

BACKGROUND/OBJECTIVE: No previous study has quantitatively investigated the degree of enhancement of pancreatic neuroendocrine tumors (pNETs) using a routine preoperative modality. The aim of this study was to evaluate the contrast-enhancement ratio (CER) of pNETs using multiphase enhanced CT and to assess the impact of the CER on disease recurrence after surgery. METHODS: A retrospective study was performed using data from 47 consecutive patients with pNETs who had undergone curative surgery. The CER of the tumor was calculated by dividing the CT attenuation value obtained during the maximum-enhanced phase by that obtained during the pre-enhanced phase. A region of interest was placed in the largest tumor dimension plane so as to cover as much surface of the tumor as possible while avoiding adjacent normal structures, calcification, and necrotic areas of the tumor. RESULTS: During a median follow-up period of 51 months (range, 1-132 months), a total of 4 patients (8.5%) developed disease recurrence. The median CER value was significantly lower for the patients with recurrence than for the patients without recurrence (2.9 vs. 4.3, P = 0.013). Univariate analyses showed that a CER ≤3.2 was significantly associated with disease recurrence (P < 0.001). All the patients with disease recurrence had tumors that were both large (>20 mm) and weakly enhanced (CER ≤ 3.2), whereas no recurrences were observed even in patients with tumors >20 mm when the CER was greater than 3.2. CONCLUSIONS: CER might be a useful predictor of disease recurrence in patients with pNETs.

Signal intensity of the pancreas on magnetic resonance imaging: Prediction of postoperative pancreatic fistula after a distal pancreatectomy using a triple-row stapler.

BACKGROUND/OBJECTIVES: The aim of this study was to evaluate the impact of the pancreatic signal intensity (SI) on magnetic resonance imaging (MRI) findings for predicting the development of pancreatic fistula (PF) after a distal pancreatectomy (DP) involving a triple-row stapler closure. METHODS: A multivariate logistic regression analysis was used to identify risk factors for clinical PF, as defined by the International Study Group on Pancreatic Fistula grade B or C. The pancreas-to-muscle SI ratio was evaluated using fat-suppressed T1-weighted MRI. RESULTS: Of the 41 enrolled patients, 8 (19.5%) developed clinical PF. The pancreatic thickness (≥15 mm) and SI ratio (≥1.3) were identified as independent predictors of clinical PF in a multivariate analysis. Clinical PF was observed in one patient with a thick pancreas and a low SI ratio (14.3%), whereas it was observed in 60% of the patients with a thick pancreas and a high SI ratio. The area under the receiver operating characteristic curve for a predictive model consisting of the two factors was 0.87 (95% confidence interval, 0.75 to 0.99), the level of which tended to be greater than that for pancreatic thickness alone (0.81, p = 0.09). CONCLUSIONS: The SI ratio as evaluated using MRI might be useful for predicting clinical PF in patients with the pancreatic thickness ≥15 mm after DP involving a stapler closure.

Multicenter comparative study of laparoscopic and open distal pancreatectomy using propensity score-matching.

BACKGROUND: Laparoscopic distal pancreatectomy has been shown to be associated with favorable postoperative outcomes using meta-analysis. However, there have been no randomized controlled studies yet. This study aimed to compare laparoscopic and open distal pancreatectomy using propensity score-matching. METHODS: We retrospectively collected perioperative data of 2,266 patients who underwent distal pancreatectomy in 69 institutes from 2006-2013 in Japan. Among them, 2,010 patients were enrolled in this study and divided into two groups, laparoscopic distal pancreatectomy and open distal pancreatectomy. Perioperative outcomes were compared between the groups using unmatched and propensity matched analysis. RESULTS: After propensity score-matching, laparoscopic distal pancreatectomy was associated with favorable perioperative outcomes compared with open distal pancreatectomy, including higher rate of preservation of spleen and splenic vessels (P < 0.001); lower rates of intraoperative transfusion (P = 0.020), clinical grade of pancreatic fistula (International Study Group on Pancreatic Fistula grade B and C; P < 0.001), and morbidity (P < 0.001); and shorter hospital stay (P = 0.001), but a longer operative time (P < 0.001). CONCLUSIONS: Laparoscopic distal pancreatectomy was associated with more favorable perioperative outcomes than open distal pancreatectomy.

Biliary tract variations of the left liver with special reference to the left medial sectional bile duct in 500 patients.

BACKGROUND: Among the intrahepatic bile ducts, the biliary system of the left medial sectional bile duct (B4) is known to have relatively complex patterns. METHODS: The records of 500 patients who had been diagnosed as having hepato-pancreatico-biliary disease were retrospectively studied for anatomical biliary variations of the left liver with special reference to the drainage system of B4 using magnetic resonance images. RESULTS: The left hepatic duct was present in 494 patients (98.8%), whereas it was lacking in 6 patients (1.2%), and these patients exhibited the following B4 confluence patterns: B4 drained into the common hepatic duct in 2 patients (.4%), the right anterior sectional bile duct in 3 patients (.6%), and the right posterior sectional bile duct in 1 patient (.2%). The left hepatic duct was absent more frequently in patients with portal venous variations than in patients with a common branching pattern (8.2% vs .4%, P = .0011). CONCLUSION: The presently reported data are useful for obtaining a better understanding of the surgical anatomy of the biliary system of the left liver.

Impact of advanced age on the short- and long-term outcomes in patients undergoing hepatectomy for hepatocellular carcinoma: a single-center analysis over a 20-year period.

BACKGROUND: The purpose of this study was to analyze the influence of age on both the risk of hepatectomy and the prognosis in patients with hepatocellular carcinoma (HCC). METHODS: Patients undergoing an initial hepatectomy for HCC were classified into 2 age groups: 75 years or over (n = 113) and less than 75 years (n = 499). RESULTS: A zero 90-day mortality was achieved in the elderly. Although the recurrence rate and recurrence sites were almost similar between the 2 groups, the 5-year survival rate in the elderly patients was significantly lower than that in the younger patients (46.0% vs 57.6%; P = .018), possibly because of the higher incidence of deaths from other causes (26.8% vs 10.4%; P = .011) in the elderly. CONCLUSION: Selected elderly HCC patients can undergo a hepatectomy safely and can benefit from long-term HCC control comparable with that of their younger counterparts.

Liver failure after hepatocellular carcinoma surgery.

PURPOSE: The aim of this study was to construct a prediction model for posthepatectomy liver failure (PHLF), as defined by the International Study Group of Liver Surgery, and evaluate its accuracy in hepatocellular carcinoma (HCC) patients with cirrhosis or chronic hepatitis. METHODS: A total of 277 consecutive hepatectomies for HCC between 2005 and 2013 were analyzed retrospectively. Multivariate logistic regression analysis was used to develop a predictive model for PHLF. The sensitivity, specificity, and area under the receiver operating characteristic (AUROC) curve were evaluated. The Hosmer-Lemeshow goodness-of-fit test was used to assess the model calibration. The constructed model was internally validated by k-fold cross-validation (k=5). RESULTS: PHLF developed in 12.6% of hepatectomies. Multivariate analysis identified the following variables as predictors of PHLF: elevated preoperative serum bilirubin level, elevated preoperative international normalized ratio, and intraoperative packed red blood cell transfusion. The predictive model allowed discrimination between patients who developed PHLF and those who did not, with a sensitivity of 82.9%, specificity of 72.3%, and AUROC curve of 0.81 (95% CI, 0.74 to 0.89). The Hosmer-Lemeshow test indicated a good fit (P=0.545). The AUROC curve of the developed model was significantly greater than that of the model for end-stage liver disease (MELD) score (P=0.014), suggesting that the former model is better at predicting the PHLF than the latter one. CONCLUSIONS: The developed model could be useful for predicting the occurrence of PHLF in HCC patients with underlying liver disease.

Surgical treatment of 144 cases of hilar cholangiocarcinoma without liver-related mortality.

BACKGROUND: The present study evaluated whether the short- and long-term outcomes improved during our 23 years of experience treating 144 consecutive patients with hilar cholangiocarcinoma. METHODS: Patients treated between 1990 and 2000 (period 1; n = 70) were retrospectively compared with those treated between 2001 and 2012 (period 2; n = 74). Mortality and major complications were defined as any death occurring within 90 days of surgery and a grade III-IV complication according to the Clavien classification, respectively. RESULTS: The mortality and major complication rates decreased from 1.2 and 34 % during period 1-0 and 24 % during period 2, respectively. Although the surgical procedure was comparable between the two periods, the median blood loss was significantly reduced from 1,020 mL during period 1-745 mL during period 2 (P = 0.003), and blood loss was the only significant predictor of postoperative morbidity in a multivariable analysis. The R0 resection rate (70 vs. 78 %, P = 0.250) and the 5-year survival rate (33 vs. 35 %, P = 0.529) were similar for the two periods. A multivariable analysis identified positive nodal involvement and R1-2 resection as independent prognostic factors for survival. CONCLUSIONS: The perioperative outcomes after surgical treatment for hilar cholangiocarcinoma have steadily improved through the accumulation of experience and meticulous surgical techniques to reduce blood loss. Further improvement of the R0 resection rate could prolong patient survival.

Assessment of treatment outcomes based on tumor marker trends in patients with recurrent hepatocellular carcinoma undergoing trans-catheter arterial chemo-embolization.

PURPOSE: The aim of the present study was to evaluate whether serum alpha-fetoprotein (AFP) and des-gamma-carboxy prothrombin (DCP) trends might be correlated with overall survival rates in patients with recurrent hepatocellular carcinoma (HCC) undergoing trans-catheter arterial chemo-embolization (TACE). METHODS: We performed a retrospective cohort study of 142 patients with recurrent HCC who were treated by TACE at our hospital from April 1990 to December 2011. Patients were divided into three groups, as follows, according to the trends of the two tumor markers AFP and DCP: the low group, comprising patients with tumor marker levels below the cutoff values (AFP 100 ng/mL and DCP 100 mAU/mL) both pre- and post-TACE; the decreased group, comprising patients with elevated tumor marker levels pre-TACE in whom the levels decreased post-TACE; and the elevated group, comprising patients with elevated tumor marker levels post-TACE. RESULT: Analysis using a Cox proportional hazards model identified the DCP trend (elevated group vs. low group, hazard ratio 8.47, 95 % confidence interval 4.53-15.84, p < 0.0001), but not the AFP trend, as an independent prognostic factor for survival. While the AFP trend was correlated only with the overall response rate assessed using the modified Response Evaluation Criteria in Solid Tumors (mRECIST; p = 0.041), the DCP trend was strongly associated with both the overall response rate (p = 0.009) and the disease control rate (p = 0.004). CONCLUSION: The DCP trend might be useful for assessing treatment outcomes after TACE in patients with recurrent HCC.

Hepatectomy preserving drainage veins of the posterior section for liver malignancy invading the right hepatic vein: an alternative to right hepatectomy.

BACKGROUND: Although a right hepatectomy (RH) traditionally has been performed for liver tumors infiltrating the main trunk of the right hepatic vein (RHV), the presence of drainage veins of the posterior section (DVPS) beside the RHV provides a chance to preserve their draining area even if the main trunk of the RHV is removed. METHODS: Since 2005, we systematically have performed DVPS-preserving hepatectomies whenever possible. In the present study, we describe our experience treating 12 consecutive patients who underwent this procedure. RESULTS: We performed the following types of liver resections concomitant with the main trunk of the RHV without packed red cell transfusion, liver failure, or 90-day mortality: extended right anterior sectionectomy in 2 patients, extended segmentectomy 7 in 3, extended segmentectomy 8 in 2, and partial resection of segment 7 in 2 and segment 8 in 3. Postoperative morbidity was observed in 4 (33%) cases, all of which had pleural effusion requiring a tap. A free resection margin was obtained in all patients. CONCLUSIONS: This procedure could be a useful alternative to RH, providing a chance for radical liver resection with minimal parenchymal sacrifice in selected patients with DVPS.

Role of bone marrow cells in the development of pancreatic fibrosis in a rat model of pancreatitis induced by a choline-deficient/ethionine-supplemented diet.

Bone marrow cell (BMC)-derived myofibroblast-like cells have been reported in various organs, including the pancreas. However, the contribution of these cells to pancreatic fibrosis has not been fully discussed. The present study examined the possible involvement of pancreatic stellate cells (PSCs) originating from BMCs in the development of pancreatic fibrosis in a clinically relevant rat model of acute pancreatitis induced by a choline-deficient/ethionine-supplemented (CDE) diet. BMCs from female transgenic mice ubiquitously expressing green fluorescent protein (GFP) were transplanted into lethally irradiated male rats. Once chimerism was established, acute pancreatitis was induced by a CDE diet. Chronological changes in the number of PSCs originating from the donor BMCs were examined using double immunofluorescence for GFP and markers for PSCs, such as desmin and alpha smooth muscle actin (αSMA), 1, 3 and 8 weeks after the initiation of CDE feeding. We also used immunohistochemical staining to evaluate whether the PSCs from the BMCs produce growth factors, such as platelet-derived growth factor (PDGF) and transforming growth factor (TGF) ß1. The percentage of BMC-derived activated PSCs increased significantly, peaking after 1 week of CDE treatment (accounting for 23.3±0.9% of the total population of activated PSCs) and then decreasing. These cells produced both PDGF and TGFß1 during the early stage of pancreatic fibrosis. Our results suggest that PSCs originating from BMCs contribute mainly to the early stage of pancreatic injury, at least in part, by producing growth factors in a rat CDE diet-induced pancreatitis model.

Transabdominal preperitoneal repair for obturator hernia.

BACKGROUND: A laparoscopic surgical approach for obturator hernia (OH) repair is uncommon. The aim of the present study was to assess the effectiveness of laparoscopic transabdominal preperitoneal (TAPP) repair for OH. METHODS: From 2001 to May 2010, 659 patients with inguinal hernia underwent TAPP repair at in our institutes. Among these, the eight patients with OH were the subjects of this study. RESULTS: Three of the eight patients were diagnosed as having occult OH, and the other five were diagnosed preoperatively, by ultrasonography and/or computed tomography, as having strangulated OH. Bilateral OH was found in five patients (63%), and combined groin hernias, either unilaterally or bilaterally, were observed in seven patients (88%), all of whom had femoral hernia. Of the five patients with bowel obstruction at presentation, four were determined not to require resection after assessment of the intestinal viability by laparoscopy. There was one case of conversion to a two-stage hernia repair performed to avoid mesh contamination: addition of mini-laparotomy, followed by extraction of the gangrenous intestine for resection and anastomosis with simple peritoneal closure of the hernia defect in the first stage, and a Kugel hernia repair in the second stage. There was no incidence of postoperative morbidity, mortality, or recurrence. CONCLUSIONS: Because TAPP allows assessment of not only the entire groin area bilaterally but also simultaneous assessment of the viability of the incarcerated intestine with a minimum abdominal wall defect, we believe that it is an adequate approach to the treatment of both occult and acutely incarcerated OH. Two-stage hernia repair is technically feasible in patients requiring resection of the incarcerated intestine.