Risk Factors for Hepatocellular Carcinoma After Splenectomy in Liver Cirrhotic Patients.

BACKGROUND: Splenectomy is sometimes indicated for portal hypertension caused by cirrhosis, which is a risk for hepatic carcinogenesis. This study aimed to identify risk factors for hepatocellular carcinoma (HCC) development after splenectomy. METHODS: This retrospective study included 65 patients who underwent splenectomy for portal hypertension between 2009 and 2017. Cox regression analyses were performed to identify factors related to HCC development after splenectomy. The predictive index for HCC development was constructed from the results of multivariate analysis, and 3 risk-dependent groups were defined. Discrimination among the groups was estimated using Kaplan-Meier curves and the log-rank test. RESULTS: Post-splenectomy, 36.9% of patients developed HCC. In the univariate analysis, the etiology of cirrhosis (hepatitis C virus antibody, P = .005, and hepatitis B surface antigen, P = .008, referring to non-B and non-C patients, respectively), presence of HCC history (P < .001), and preoperative hemoglobin level (P = .007) were related to HCC development, and the presence of HCC history (P = .002) and preoperative hemoglobin level (P = .022) were independent risk factors. The predictive index classified three groups at risk; the hazards in each group were significantly different (low vs middle risk, P = .035, and middle vs high risk, P = .011). DISCUSSION: The etiology of cirrhosis, presence of HCC history, and hemoglobin level were associated with HCC development after splenectomy. The predictive model may aid in HCC surveillance after splenectomy for patients with portal hypertension.

Clostridium butyricum affects nutrition and immunology by modulating gut microbiota.

The gut microbiota has nutritional and protective functions. In patients with end-stage renal disease, changes in the gut microbiota disrupt their protective functions. Probiotics help maintain normal bowel function. However, their role in patients with end-stage renal disease is controversial. We investigated whether Clostridium butyricum affects the nutrition and immune function of patients with end-stage renal disease undergoing maintenance dialysis between 2014 and 2015; thirty-seven patients were included. The patients were divided into two groups: one in which C. butyricum was administered and one in which it was not. One tablet of the probiotics, which contained 20 mg of C. butyricum, was administered orally three times daily for 2 years in the C. butyricum group. The 16S rRNA genes were sequenced from stool samples of 14 (37.8%) patients in the C. butyricum group and 23 (62.2%) patients in the control group. The differences in the gut microbiota of the two groups were analyzed. The α-diversity index indicated that the C. butyricum group had significantly more operational taxonomic units and higher albumin and transferrin levels than the control group. The effector to target cell ratio was significantly higher in the C. butyricum group. In addition, interleukin-6 levels were significantly lower in the C. butyricum group, and inflammation was less severe in this group. The patients undergoing maintenance dialysis with C. butyricum had abundant gut microbiota. They also had a good nutritional status, low systemic inflammation, and a good immunological status.

Liver resection is associated with good outcomes for hepatocellular carcinoma patients beyond the Barcelona Clinic Liver Cancer criteria: A multicenter study with the Hiroshima Surgical study group of Clinical Oncology.

BACKGROUND: Liver resection for hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer criteria remains controversial. Strict candidate selection is crucial to achieve optimal results in this population. This study explored postoperative outcomes and developed a preoperative predictive formula to identify patients most likely to benefit from liver resection. METHODS: In total, 382 patients who underwent liver resection for hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer resection criteria between 2000 and 2017 were identified from a multicenter database with the Hiroshima Surgical study group of Clinical Oncology. An overall survival prediction model was developed, and patients were classified by risk status. RESULTS: The 5-year overall survival after curative resection was 50.0%. Overall survival multivariate analysis identified that a high a-fetoprotein level, macrovascular invasion, and high total tumor burden were independent prognostic risk factors; these factors were used to formulate risk scores. Patients were divided into low-, moderate-, and high-risk groups; the 5-year overall survival was 65.7%, 49.5%, and 17.0% (P < .001), and the 5-year recurrence-free survival was 31.3%, 26.2%, and 0%, respectively (P < .001). The model performance was good (C-index, 0.76). Both the early and extrahepatic recurrence increased with higher risk score. CONCLUSION: The prognosis of patients with hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer resection criteria depended on a high a-fetoprotein level, macrovascular invasion, and high total tumor burden, and risk scores based on these factors stratified the prognoses. Liver resection should be considered in patients with hepatocellular carcinoma beyond the Barcelona Clinic Liver Cancer criteria with a low or moderate-risk score.

Significance of liver resection for intermediate stage hepatocellular carcinoma according to subclassification.

BACKGROUND: Patients diagnosed with Barcelona Clinic Liver Cancer (BCLC) intermediate stage hepatocellular carcinoma (HCC) encompass a broad clinical population. Kinki criteria subclassifications have been proposed to better predict prognoses and determine appropriate treatment strategies for these patients. This study validated the prognostic significance within the Kinki criteria substages and analyzed the role of liver resection in patients with intermediate stage HCC. METHODS: Patients with intermediate stage HCC (n = 378) were retrospectively subclassified according to the Kinki criteria (B1, n = 123; B2, n = 225; and B3, n = 30). We analyzed the overall survival (OS) and treatment methods. RESULTS: The OS was significantly different between adjacent substages. Patients in substage B1 who underwent liver resection had a significantly better prognosis than those who did not, even after propensity score matching (PSM). Patients in substage B2 who underwent liver resection had a significantly better prognosis than those who did not; however, there was no difference after PSM. There was no difference in prognosis based on treatments among patients in substage B3. CONCLUSIONS: The Kinki criteria clearly stratify patients with intermediate stage HCC by prognosis. For substage B1 HCC patients, liver resection provides a better prognosis than other treatment modalities. In patients with substage B2 and B3, an alternative approach is required.

Effect of increased blood flow rate on renal anemia and hepcidin concentration in hemodialysis patients.

BACKGROUND: Increasing the blood flow rate (BFR) is a useful method for increasing Kt/V and the clearance for low molecular solutes. Hemodialysis patients are often anemic due to hypoerythropoiesis and their chronic inflammatory state. Hepcidin, a hormone that regulates iron homeostasis, is considered as an indicator of iron deficiency in patients with end-stage renal disease. This study aimed to investigate the effects of an increased BFR during hemodialysis on serum hepcidin levels and anemia. METHODS: Between April 2014 and March 2016, 22 chronic dialysis patients (11 men [50.0 %]; mean [± standard deviation] age, 72 ± 12 years) undergoing maintenance hemodialysis treatment, thrice weekly, were enrolled and followed prospectively for 24 months. In April 2014, the BFR was 200 mL/min; in April 2015 this was increased to 400 mL/min, which was within acceptable limits. The dialysate flow rate remained stable at; 500mlL/min. Blood samples were collected in March 2015 and 2016. The primary endpoint was the comparison of the amounts of erythropoiesis-stimulating agent (ESA) required. RESULTS: The increased BFR increased the Kt/V and contributed to significantly decreased urea nitrogen (UN) (p = 0.015) and creatinine (Cr) (p = 0.005) levels. The dialysis efficiency was improved by increasing the BFR. Ferritin (p = 0.038), hepcidin (p = 0.041) and high-sensitivity interleukin-6 (p = 0.038) levels were also significantly reduced. The ESA administered was significantly reduced (p = 0.004) and the Erythropoietin Resistant Index (ERI) significantly improved (p = 0.031). The reduction rates in UN (p < 0.001), Cr (p < 0.001), and beta-2 microglobulin (p = 0.017) levels were significantly greater post the BFR increase compared to those prior to the BFR increase. However, hepcidin was not affected by the BFR change. CONCLUSIONS: Increasing BFR was associated with hemodialysis efficiency, and led to reduce inflammatory cytokine interleukin-6, but did not contribute to reduce C-reactive protein. This reduced hepcidin levels, ESA dosage and ERI. Hepcidin levels were significantly correlated with ferritin levels, and it remains to be seen whether reducing hepcidin leads to improve ESA and iron availability during anemia management.

Improved safety of induced pluripotent stem cell-derived antigen-presenting cell-based cancer immunotherapy.

The tumorigenicity and toxicity of induced pluripotent stem cells (iPSCs) and their derivatives are major safety concerns in their clinical application. Recently, we developed granulocyte-macrophage colony-stimulating factor (GM-CSF)-producing proliferating myeloid cells (GM-pMCs) from mouse iPSCs as a source of unlimited antigen-presenting cells for use in cancer immunotherapy. As GM-pMCs are generated by introducing c-Myc and Csf2 into iPSC-derived MCs and are dependent on self-produced GM-CSF for proliferation, methods to control their proliferation after administration should be introduced to improve safety. In this study, we compared the efficacy of two promising suicide gene systems, herpes simplex virus-thymidine kinase (HSV-TK)/ganciclovir (GCV) and inducible caspase-9 (iCasp9)/AP1903, for safeguarding GM-pMCs in cancer immunotherapy. The expression of HSV-TK or iCasp9 did not impair the fundamental properties of GM-pMCs. Both of these suicide gene-expressing cells selectively underwent apoptosis after treatment with the corresponding apoptosis-inducing drug, and they were promptly eliminated in vivo. iCasp9/AP1903 induced apoptosis more efficiently than HSV-TK/GCV. Furthermore, high concentrations of GCV were toxic to cells not expressing HSV-TK, whereas AP1903 was bioinert. These results suggest that iCasp9/AP1903 is superior to HSV-TK/GCV in terms of both safety and efficacy when controlling the fate of GM-pMCs after priming antitumor immunity.

PD1 gene polymorphism is associated with a poor prognosis in hepatocellular carcinoma following liver resection, cohort study.

BACKGROUND: This study examined whether single nucleotide polymorphism (SNP) in programmed cell death protein (PD)-1 is related to the postoperative prognosis of patients with hepatocellular carcinoma (HCC). The immune checkpoint protein PD-1 is an important inhibitor of T cell responses. SNP in the promoter region of PD-1 -606 G/A has been reported to result in high activation and expression of PD-1 associated with cancer risk. MATERIALS AND METHODS: We analyzed 321 patients with HCC who underwent hepatectomy between 2010 and 2015. PD-1 SNP was analyzed by polymerase chain reaction, and the prognosis after surgical treatment of patients with HCC was analyzed. RESULTS: The PD-1 SNP statuses were as follows: 90 AA (28.1%), 163 GA (50.8%), 68 GG (21.2%). The baseline parameters did not statistically differ between the three groups. The overall survival (OS) of patients with the GG genotype was significantly lower than that of those with the other genotypes (P = 0.031). The GG genotype was an independent risk factor for OS (P = 0.009; HR 2.201). There was no significant difference between the GG genotype and other genotypes in recurrent-free survival. The extrahepatic recurrence (EHR) rate of those with the GG genotype was significantly higher than that of those with the other genotypes (P = 0.036). The GG genotype was an independent risk factor for EHR (P = 0.008; HR 2.037). CONCLUSIONS: The PD-1 SNP GG genotype is associated with poor survival and increased EHR in HCC. Furthermore, the GG genotype is an independent predictive factor for OS and EHR.

Hemorrhoidectomy for elderly patients aged 75 years or more, before and after studies.

BACKGROUND: The incidence of hemorrhoids requiring hemorrhoidectomy among the elderly has been increasing. Old age is sometimes considered a contraindication for surgery. The relationship between age and complications of hemorrhoidectomy for elderly patients is not well established. This study aimed to compare the clinicopathological features and postoperative outcomes of hemorrhoidectomy in the elderly (≥75 years old) and non-elderly patients (<75 years old). METHODS: A total of 100 patients who underwent hemorrhoidectomy for hemorrhoids of Goligher classification grades 3 and 4 at our institution between 2014 and 2018 were enrolled. The clinical characteristics were compared between the elderly and non-elderly patients. Pain scores were measured at 6, 12, 24, and 48 h after surgery. The risk factors for postoperative complications were identified. RESULTS: A total of 34 patients were classified as elderly patients. In the elderly group, aspartate aminotransferase levels were higher while the albumin levels and cholinesterase levels were lower and the platelet counts were significantly lower. The blood urea nitrogen levels were higher and estimated glomerular filtration rates and hemoglobin levels were significantly lower in the elderly group. The pain scores significantly decreased at 48 h postoperatively compared to those recorded at 6 h postoperatively in both groups. Multivariate analysis identified Goligher classification grade 4 and high neutrophil to lymphocyte ratio at the indicators of complications. CONCLUSIONS: Hemorrhoids due to impairment of liver function and kidney function were dominant in elderly patients. Aging itself was not a risk factor for postoperative complications.

Impact of postoperative bile leakage on long-term outcome in patients following liver resection for hepatocellular carcinoma.

BACKGROUND/PURPOSE: The incidence of bile leakage after liver resection for hepatocellular carcinoma (HCC) remains a cause for concern. There are limited reports on the impacts of postoperative bile leakage on long-term clinical outcomes. This study aims to evaluate the effects of postoperative bile leakage on recurrence-free survival (RFS) and overall survival (OS). METHODS: A total of 1,178 patients who underwent curative liver resection for HCC between 1986 and 2012 were included in the present study. Postoperative bile leakage was defined using the International Study Group of Liver Surgery definition, and the primary end points of the study were OS and RFS at 5 years. RESULTS: Forty-three (3.7%) patients had bile leakage following liver resection. The median follow-up was 5 years. A follow-up analysis revealed that patients with bile leakage had poor 5-year rates of OS (41.0% vs 56.4%, P = .013) and RFS (14.6% vs 28.7%, P < .001). Additionally, bile leakage was an independent factor for both OS [hazard ratio (HR) 1.559, P = .022] and RFS (HR 1.517, P = .024). Furthermore, bile leakage was the only factor affecting prognosis among postoperative complications. CONCLUSIONS: Postoperative bile leakage worsens long-term clinical outcomes following liver resection in HCC patients.

Generation of GM-CSF-producing antigen-presenting cells that induce a cytotoxic T cell-mediated antitumor response.

Immunotherapy using dendritic cells (DCs) is a promising treatment modality for cancer. However, the limited number of functional DCs from peripheral blood has been linked to the unsatisfactory clinical efficacies of current DC-based cancer immunotherapies. We previously generated proliferating antigen-presenting cells (APCs) by genetically engineering myeloid cells derived from induced pluripotent stem cells (iPSC-pMCs), which offer infinite functional APCs for broad applications in cancer therapy. Herein, we aimed to further enhance the antitumor effect of these cells by genetic modification. GM-CSF gene transfer did not affect the morphology, or surface phenotype of the original iPSC-pMCs, however, it did impart good viability to iPSC-pMCs. The resultant cells induced GM-CSF-dependent CD8+ T cell homeostatic proliferation, thereby enhancing antigen-specific T cell priming in vitro. Administration of the tumor antigen-loaded GM-CSF-producing iPSC-pMCs (GM-pMCs) efficiently stimulated antigen-specific T cells and promoted effector cell infiltration of the tumor tissues, leading to an augmented antitumor effect. To address the potential tumorigenicity of iPSC-derived products, irradiation was applied and found to restrict the proliferation of GM-pMCs, while retaining their T cell-stimulatory capacity. Furthermore, the irradiated cells exerted an antitumor effect equivalent to that of bone marrow-derived DCs obtained from immunocompetent mice. Additionally, combination with immune checkpoint inhibitors increased the infiltration of CD8+ or NK1.1+ effector cells and decreased CD11b+/Gr-1+ cells without causing adverse effects. Hence, although GM-pMCs have certain characteristics that differ from endogenous DCs, our findings suggest the applicability of these cells for broad clinical use and will provide an unlimited source of APCs with uniform quality.

Laparoscopic versus open limited liver resection for hepatocellular carcinoma with liver cirrhosis: a propensity score matching study with the Hiroshima Surgical study group of Clinical Oncology (HiSCO).

BACKGROUND: Laparoscopic liver resection (LLR) has evolved as a safe and effective alternative to conventional open liver resection (OLR) for malignant lesions. However, LLR in cirrhotic patients remains challenging. This study analyzed the perioperative and oncological outcomes of LLR for hepatocellular carcinoma (HCC) with cirrhosis compared with OLR using propensity score matching. METHODS: A multicenter retrospective analysis of records of patients who underwent limited liver resection for HCC and were histologically diagnosed with liver cirrhosis between January 2009 and December 2017 in the eight institutions belonging to the Hiroshima Surgical study group of Clinical Oncology was performed. The patients were divided into two groups: the LLR and OLR groups. After propensity score matching, we compared clinicopathological features and outcomes. RESULTS: In total 256 patients with histological liver cirrhosis who underwent limited liver resection for HCC were included in this study; 58 patients had undergone LLR, and the remaining 198 patients OLR. The number of tumors was higher, tumor size was larger, and difficulty score was significantly higher in the OLR group before propensity matching. After the matching, the data of the well-matched 58 patients in each group were evaluated; the intraoperative blood loss was lower in the LLR group (p = 0.004), and incidence of the postoperative complications was significantly higher in the OLR group (p = 0.019). The duration of the postoperative hospital stay was significantly shorter in the LLR group (p < 0.001). There were no differences between two groups in overall survival and recurrent-free survival. CONCLUSIONS: LLR decreased the incidences of postoperative complications, shortened the duration of postoperative hospital stay. Thus, LLR is a safe and feasible procedure even in patients with cirrhosis.

Verification of inflammation-based prognostic marker as a prognostic indicator in hepatocellular carcinoma.

AIM: Although inflammation-based markers in cancer have been used for prognostic prediction, the most useful marker for hepatocellular carcinoma (HCC) has not been established. We investigated the usefulness of various inflammation-based markers in HCC patients after hepatectomy. METHODS: A total of 478 patients who underwent initial hepatectomy for HCC from 2009 to 2015 and were diagnosed with pathological HCC were included in this retrospective study. Inflammation-based markers consisted of the C-reactive protein to albumin ratio (CAR), Glasgow prognostic score (GPS), neutrophil to lymphocyte ratio, lymphocyte to monocyte ratio, platelet to lymphocyte ratio and prognostic index. Univariate and multivariate analyses for overall survival (OS) and disease-free survival (DFS) using the Cox proportional hazard model were carried out. Kaplan-Meier analysis and log-rank test were used for comparison of OS and DFS. To reduce influences of selection bias and confounders for stratifying CAR, clinicopathological characteristics of patients were balanced by propensity score matching. RESULTS: Multivariate analysis identified only high CAR (>0.027) as an indicator of poor OS, and high CAR and high GPS (1-2) as indicators of poor DFS among inflammation-based markers. After propensity score matching, 124 patients each with low CAR and high CAR were matched. High CAR was correlated with both poor OS and DFS. CONCLUSION: C-reactive protein to albumin ratio was the most valuable prognostic indicator after hepatectomy for HCC among inflammation-based markers.

Experience and outcomes in living donor liver procurement using the water jet scalpel.

BACKGROUND: The aim of the present study was to clarify treatment outcomes of living donor liver procurement using the water jet scalpel (WJS). METHODS: This single-center, retrospective cohort study included 40 living donors who underwent liver procurement from January 2014 to December 2018. One living donor who underwent posterior segmentectomy was excluded. Clinical data and outcomes after surgery for 20 WJS donors and 19 Cavitron Ultrasonic Surgical Aspirator (CUSA) donors were compared. RESULTS: Preoperative and excised graft data did not differ significantly between the WJS and CUSA groups. Operation time (P = 0.025) and parenchymal transection time (P = 0.007) were significantly shorter in the WJS group. There was no difference between the groups in terms of short-term outcomes after surgery. Multivariate analysis revealed that WJS offered significant advantages over CUSA in terms of shortening parenchymal transection time (P = 0.017). CONCLUSION: Living donor liver procurement using WJS contributes to shortening of parenchymal transection time while maintaining the same level of safety as when using CUSA.

Synchronous double primary hepatic cancer consisting of hepatocellular carcinoma and cholangiolocellular carcinoma: a case report.

BACKGROUND: The incidence of synchronous double primary hepatic cancers is extremely low. Cholangiolocellular carcinoma is also a rare disease. CASE PRESENTATION: A 58-year-old Japanese man was referred to our hospital for the treatment of multiple liver tumors revealed on computed tomography scans. He was hepatitis B and C positive and had undergone hemodialysis for 9 years due to chronic renal failure. Computed tomography scans revealed two hepatic tumors (each ≤ 1.0 cm in diameter) in segments 3 and 7. The preoperative diagnosis was multiple hepatocellular carcinomas. He underwent partial resections of his liver. The resected specimens revealed that the tumors in segments 3 and 7 were well-defined lesions of 8.0 mm and 14.0 mm, respectively. Pathological and immunohistochemical examinations confirmed the tumor in segment 3 to be a cholangiolocellular carcinoma and the tumor in segment 7 to be a hepatocellular carcinoma. Chronic inflammation could contribute to the different types of primary hepatic cancers. It may also give rise to various combinations of synchronous double primary hepatic cancer in patients with chronic liver disease. CONCLUSIONS: We describe the sixth case of synchronous double primary hepatic cancers consisting of hepatocellular carcinoma and cholangiolocellular carcinoma in chronic damaged liver and review the literature. In patients with chronic liver disease, careful surveillance with imaging studies should be mandatory as various types of primary hepatic cancers could develop.

Laparoscopic management of refractory chylous ascites using fluorescence navigation with indocyanine green: A case report.

INTRODUCTION: Postoperative chylous ascites is a rare complication of colorectal surgery. Conservative management is usually effective in most cases of the postoperative chylous ascites. However, surgical intervention is performed for refractory cases. PRESENTATION OF CASE: A 31-year-old man with neuroendocrine carcinoma developed chylous ascites after laparoscopic descending colectomy with D3 lymphadenectomy. Conservative treatment including total parenteral nutrition and somatostatin analogue failed and surgical intervention via laparoscopy was performed for the refractory chylous ascites. Lymphatic leakage was detected at the upper part of the inferior mesenteric artery during the laparoscopic exploration and was reconfirmed by intraoperative indocyanine green injection with an infrared camera system. Moreover, we injected the ICG into the other sites of the lymphadenectomy performed and identified the lymphatic flow. We confirmed there was no other lymphatic leakage. The lesion was ligated and closed with fibrin glue. Five months after the surgical intervention, no symptom was noted. DISCUSSION: It is frequently difficult to detect the site of lymphatic leakage intraoperatively. Intraoperative indocyanine green injection is useful for detecting a lymphatic leakage site and especially making sure without other leakages. Additionally, laparoscopic surgery seems safe and effective for refractory chylous ascites. CONCLUSION: we reported successful laparoscopic management of refractory chylous ascites using fluorescence navigation with indocyanine green.

Left colic artery-preserving D3 lymphadenectomy using near-infrared spectroscopy was effective for double advanced cancers of the transverse colon and rectum: A case report.

INTRODUCTION: Exact assessment of intestinal viability is necessary, since the risk of anastomotic complications increases due to the reduction in anastomotic blood supply. Near-infrared spectroscopy is useful in assessing blood flow because it allows real-time monitoring and quantifying of tissue oxygen saturation. Herein, we report a case in which two intestinal resections were performed safely by using near-infrared spectroscopy to evaluate the blood flow at the anastomotic sites. PRESENTATION OF CASE: A 67-year-old man was diagnosed with multiple cancers of the transverse colon and rectum. Laparoscopic transverse colon resection and low anterior resection were performed along with left colic artery-preserving lymphadenectomy, including tissues around the origin of the inferior mesenteric artery. After mesenteric dissection, the tissue oxygen saturation of the proximal side and distal side stumps were 93% and 87%, respectively. The tissue oxygen saturation of the anastomotic proximal side after mesenteric dissection was 76%, thus confirming sufficient blood flow. DISCUSSION: Performance of transverse colon resection and low anterior resection for multiple cancers of the transverse colon and rectum resulted in blockage of the blood flow to the descending colon; therefore, it was necessary to preserve the blood flow to the descending colon by preserving the left colic artery. Near-infrared spectroscopy was used to evaluate blood flow to the anastomotic sites, in order to perform the surgery safely. CONCLUSION: Near-infrared spectroscopy is a safe, simple and low-cost method for assessing blood flow intraoperatively in conjunction with left colic artery-preserving surgery.

Celiac axis stenosis due to median arcuate ligament compression in a patient who underwent pancreatoduodenectomy; intraoperative assessment of hepatic arterial flow using Doppler ultrasonography: a case report.

BACKGROUND: Celiac axis stenosis due to compression by the median arcuate ligament has been reported in patients undergoing pancreaticoduodenectomy; it leads to the development of major collateral pathways that feed the hepatic artery. Dividing these important collaterals during pancreaticoduodenectomy can cause ischemic complications which may lead to a high mortality rate. To prevent these complications, it is necessary to assess intrahepatic arterial flow. CASE PRESENTATION: A 71-year-old Japanese man with anorexia was referred to us for the treatment of alcoholic chronic pancreatitis. Computed tomography revealed a pancreatic head tumor with a calculus, associated with the dilatation of the main pancreatic duct and intrahepatic bile duct. Three-dimensional imaging demonstrated focal narrowing in the proximal celiac axis due to median arcuate ligament compression and a prominent gastroduodenal artery that fed the common hepatic artery. The preoperative diagnosis was alcoholic chronic pancreatitis with common bile duct obstruction and celiac axis stenosis due to median arcuate ligament compression. Pancreaticoduodenectomy with median arcuate ligament release was scheduled. Before the division of the median arcuate ligament, the peak flow velocity and resistive index of his intrahepatic artery measured with Doppler ultrasonography decreased from 37.7 cm/second and 0.510, respectively, to 20.6 cm/second and 0.508 respectively, when his gastroduodenal artery was clamped. However, these values returned to baseline levels after the division of the median arcuate ligament. These findings suggested that pancreaticoduodenectomy could be performed safely. Our patient was discharged on postoperative day 17 without significant complications. CONCLUSION: The intraoperative quantitative evaluation of intrahepatic arterial blood flow using Doppler ultrasonography was useful in a patient who underwent pancreaticoduodenectomy, who had celiac axis stenosis due to compression by the median arcuate ligament.

Visceral obesity is a significant risk factor for incisional hernia after laparoscopic colorectal surgery: A single-center review.

INTRODUCTION: Although laparoscopic surgery uses relatively small incisions, incisional hernia after surgery is not uncommon. However, the incidence of incisional hernia and its risk factors are not well known. The purpose of our study was to investigate risk factors for incisional hernia after laparoscopic colorectal cancer surgery. METHODS: The study group consisted of 212 patients who underwent laparoscopic colorectal cancer surgery at Hiroshima Prefectural Hospital between November 2008 and October 2013. Diagnosis of incisional hernia was performed by postoperative CT. The visceral fat area (VFA) and subcutaneous fat area at the level of the umbilicus were calculated using an image analysis system. For statistical analysis, Fisher's exact test or Student's t-test were used for univariate analysis, and logistic regression analysis was used for multivariate analysis. The cut-off value for risk factors was calculated from the receiver-operator curve. RESULTS: Incisional hernia was observed in 18 patients (8.5%). On univariate analysis, female sex (P = 0.04), older age (P = 0.02), subcutaneous fat area (P < 0.01), VFA (P = 0.02), and BMI >25 kg/m2 (P < 0.01) were significant risk factors for incisional hernia. The predictive cut-off values were as follows: age, 72 years; subcutaneous fat area, 110 cm2 ; VFA, 110 cm2 ; and albumin concentration, 3.9 g/dL. On multivariate analysis, a VFA >110 cm2 (P < 0.01) and female sex (P = 0.01) were retained as independent risk factors for incisional hernia. CONCLUSION: After laparoscopic colorectal cancer surgery, a higher VFA and female sex are independent risk factors for incisional hernia.

Utility of hepatobiliary scintigraphy for recurrent reflux cholangitis following choledochojejunostomy: A case report.

INTRODUCTION: Reflux cholangitis is a frequent complication of Roux-en-Y choledochojejunostomy. PRESENTATION OF CASE: A 68-year-old male underwent left lobectomy of the liver, bile duct resection and choledochojejunostomy for intrahepatic cholangiocarcinoma located in Segment 2 of the liver, 40mm in diameter with a lymph node metastasis 5 years ago. He had frequent recurrences of postoperative reflux cholangitis and hepatic abscesses and was treated with antibiotics each time. Postoperative adjuvant chemotherapy was scheduled, but due to recurrent cholangitis it was difficult. Although double balloon endoscopy for endoscopic retrograde cholangiography was performed, no stenosis was found in the choledochojejunostomy anastomosis, and no defect suspected of calculus and stenosis were found by contrast. Antibiotics had to be administered for a long time because it recurred when antibiotics were discontinued. This time, a tumor 2.0cm in diameter was detected in segment 7 of the liver on follow - up computed tomography. The preoperative diagnosis was recurrent Intrahepatic cholangiocarcinoma. Hepatobiliary scintigraphy was carried out in preparation for concomitant treatment of his reflux cholangitis. Retention in the blind loop of the choledochojejunostomy was retarded, and the excretion was delayed. Therefore, hepatectomy and resection of the blind loop were performed. We confirmed improvement of stasis in the blind loop on postoperative hepatobiliary scintigraphy. The postoperative course was uneventful, and antibiotics were not required. DISCUSSION: Hepatobiliary scintigraphy may be able to clarify the mechanism underlying reflux cholangitis. CONCLUSION: Hepatobiliary scintigraphy was useful for the treatment of recurrent reflux cholangitis in this case.

Utility of single-incision totally extraperitoneal inguinal hernia repair with intraperitoneal inspection.

AIM: To study the utility of single-incision totally extraperitoneal inguinal hernia repair with intraperitoneal inspection. METHODS: A 2 cm transverse skin incision was made in the umbilicus, extending to the intraperitoneal cavity. Carbon dioxide was insufflated followed by insertion of laparoscope to observe the intraperitoneal cavity. The type of hernia was diagnosed and whether there was the presence of intestinal incarceration was confirmed. When an intestinal incarceration in the hernia sac was found, the forceps were inserted through the incision site and the intestine was returned to the intraperitoneal cavity without increasing the number of trocars. Once the peritoneum was closed, totally extraperitoneal inguinal hernia repair was performed, and finally, intraperitoneal observation was performed to reconfirm the repair. RESULTS: Of the 75 hernias treated, 58 were on one side, 17 were on both sides, and 10 were recurrences. The respective median operation times for these 3 groups of patients were 100 min (range, 66 to 168), 136 min (range, 114 to 165), and 125 min (range, 108 to 156), with median bleeding amounts of 5 g (range, 1 to 26), 3 g (range, 1 to 52), and 5 g (range, 1 to 26), respectively. Intraperitoneal observation showed hernia on the opposite side in 2 cases, intestinal incarceration in 3 cases, omental adhesion into the hernia sac in 2 cases, severe postoperative intraperitoneal adhesions in 2 cases, and bladder protrusion in 1 case. There was only 1 case of recurrence. CONCLUSION: Single-incision totally extraperitoneal inguinal hernia repair with intraperitoneal inspection makes hernia repairs safer and reducing postoperative complications. The technique also has excellent cosmetic outcomes.