Skeletal Muscle Mass Index Reduction Rate as a Prognostic Indicator for Patients Undergoing Pancreatectomy for Pancreatic Cancer.

Background/Aim: There have been many studies on skeletal muscle depletion before surgery, and skeletal muscle depletion is a known risk factor for poor prognosis. However, reports on the association between changes in skeletal muscle mass and prognosis after surgery for pancreatic cancer are very few. Patients and Methods: The data of 137 patients who underwent pancreatectomy for pancreatic cancer between 2005 and 2022 were reviewed. Muscle areas were measured at the third lumbar vertebral level, and skeletal muscle mass index (SMI) reduction rates were calculated. Patients were divided into two groups using receiver operating characteristic (ROC) curve analysis based on the SMI reduction rate with a cutoff of 14% reduction rate. The clinicopathological factors, overall survival (OS), and recurrence-free survival (RFS) were compared between the two groups. Survival rates were analyzed both univariately and multivariately to clarify the factors associated with poor prognosis after pancreatectomy. Results: A total of 102 patients met the inclusion criteria. SMI reduction rate ≥14% significantly correlated with advanced age and higher incidence of postoperative complications. In the multivariate Cox regression analysis, preoperative prognostic nutritional index (PNI) <40 and SMI reduction rate ≥14% were significantly associated with poor OS. Tumor size ≥3.0 cm, preoperative neutrophile-lymphocyte ratio ≥3.0, and SMI reduction rate ≥14% were significantly associated with poor RFS. Conclusion: The rate of skeletal muscle mass reduction after pancreatic surgery is an independent prognostic factor for survival in patients with pancreatic cancer.

A case of difficult-to-diagnose hepatic reactive lymphoid hyperplasia finally diagnosed by using PCR analysis of IgH-gene rearrangements: a case report.

Reactive lymphoid hyperplasia (RLH) of the liver is extremely rare. Despite advancements in diagnostic imaging technology, it is still difficult to distinguish from hepatocellular carcinoma (HCC). Herein, we present a case of hepatic RLH mimicking HCC that was postoperatively diagnosed using several imaging modalities. A 78-year-old female was referred to our hospital with a positive hepatitis C virus antibody (HCV Ab) test. Ultrasonography revealed a 13 mm isoechoic lesion in segment 8 of the liver. Contrast-enhanced computed tomography (CE-CT) demonstrated arterial hyperintensity and washout during the later phase. On ethoxybenzyl magnetic resonance imaging (EOB-MRI), the lesion was hyperenhanced in the arterial phase and of low intensity in the hepatocyte phase. Although the tumor markers were all within normal limits, the pattern of contrast enhancement of the tumor on CT and MRI was consistent with that of HCC. We performed S8 segmentectomy of the liver. Histological examination of the resected specimen revealed dense lymphoid tissue of variable sizes and shapes with expanded germinal centers. Immunohistochemical examination was positive for CD3, CD10 (germinal center), and CD20, and negative for B-cell lymphoma 2 (bcl-2) (germinal center) and Epstein-Barr virus (EBV). A polymerase chain reaction (PCR) analysis of IgH-gene rearrangements revealed polyclonality. Based on these findings, hepatic RLH was diagnosed. The postoperative course was uneventful, and the patient was discharged on the 10th postoperative day. She had a good quality of life after surgery and no liver nodule recurrence was detected at the 4-month medical follow-up. Hepatic RLH is an extremely rare disease and preoperative diagnosis is difficult. This should be considered in the differential diagnosis of single small hepatic tumors. An echo-guided biopsy and careful observation of imaging may help diagnose hepatic RLH, and a PCR analysis of IgH-gene rearrangements would be necessary for the definitive diagnosis of hepatic RLH.

Lethal multiple colon necrosis and perforation due to fulminant amoebic colitis: a surgical case report and literature review.

BACKGROUND: Amoebiasis caused by the protozoan species Entamoeba histolytica rarely develops into fulminant amoebic colitis (FAC), but when it does, it shows an aggressive clinical course including colonic perforation, necrotizing colitis, and high mortality. Surgical treatment for FAC patients should be carried out urgently. However, even after surgery, the mortality rate can be 40-50%. Although FAC is one of the most unfavorable surgical diseases with a poor prognosis, there are a few reports on the perioperative diagnosis and management of FAC based on autopsy findings. We herein report the surgical case of a 64-year-old man who developed multiple colon necrosis and perforation due to FAC. A detailed autopsy revealed FAC as the cause of death. Additionally, we reviewed the existing literature on FAC patients who underwent surgery and followed their perioperative diagnosis and management. CASE PRESENTATION: A 64-year-old man presented with anorexia, diarrhea, and altered consciousness on arrival to our hospital. Computed tomography revealed a large mass in the upper right lobe of his lung, and the patient was admitted for close investigation. Bloody diarrhea, lower abdominal pain, and hypotension were observed soon after admission. Urgent abdominal contrast-enhanced computed tomography scan revealed extensive intestinal ischemia, intestinal pneumatosis, and free intra-abdominal gas. The preoperative diagnosis was bowel necrosis and perforation with intussusception of the small intestinal tumor. Emergency subtotal colectomy and enterectomy were performed soon after the contrast-enhanced computed tomography. He was taken to an intensive care unit after surgery. However, he could not recover from sepsis and died with disseminated intravascular coagulation and multiple organ failure on the 10th-day post-surgery. A histopathological examination of the resected colon showed transmural necrosis and massive amoebae invasion. He was diagnosed with FAC. An autopsy revealed that he had developed pulmonary large cell carcinoma with small intestinal metastasis. The death was caused by intestinal ischemia, necrosis and the perforation of the residual bowel caused by amoebae invasion. CONCLUSIONS: Since FAC is a lethal disease with a high mortality rate and antibiotic therapies except metronidazole are ineffective, preoperative serological testing and perioperative metronidazole therapy in FAC patients can dramatically improve their survival rates.

Branch-type intraductal papillary neoplasm of the bile duct treated with laparoscopic anatomical resection: a case report.

BACKGROUND: Intraductal papillary neoplasm of the bile duct (IPNB) is characterized by an intraluminal, growing papillary tumor covered by neoplastic biliary epithelial cells with a fine fibrovascular core. IPNB was introduced as a precancerous and early neoplastic lesion in the 2010 World Health Organization classification of tumors of the digestive system. IPNB eventually invades the bile duct wall and progresses to invasive cholangiocarcinoma. IPNB resembles intraductal papillary mucinous neoplasm of the pancreas (IPMN), particularly the main pancreatic duct type. IPNB cases, possibly corresponding to branch-type IPMN, have been recently reported, and these cases involved the peribiliary glands significantly and showed gross cystic dilatation. Small branch-type intrahepatic IPNB often mimics simple liver cysts, making the diagnosis of IPNB difficult. Some literature recommended surgical resection for treatment. Laparoscopic resection is a good treatment option for small tumor. We herein present the case of branch-type IPNB that was treated with laparoscopic anatomical liver resection 5 years after being detected. CASE PRESENTATION: A 64-year-old woman was undergoing follow-up for primary aldosteronism. In 2012, follow-up computed tomography (CT) incidentally revealed a 7-mm cystic lesion in segment 8 of the liver. From 2012 to 2017, the cystic lesion kept increasing in size, reaching 17 mm. In 2017, CT also revealed a 13-mm mural nodule in the cyst wall. Therefore, the patient was referred to our department for possible malignancy. We suspected a branch-type IPNB; however, the mass was small and diagnosis could not be made without performing biopsy. Accordingly, surgical resection was performed for diagnosis and treatment. Because branch-type IPNB might show horizontal spread through the intrahepatic bile duct, we believed that anatomical resection of the liver was appropriate considering the malignant potential of the lesion. Therefore, laparoscopic anatomical resection of segment 8 of the liver was performed. The resected tumor measured 17 mm and was histologically diagnosed as a high-grade IPNB. CONCLUSION: Branch-type IPNBs are rare but can potentially lead to malignant tumors. Surgical resection is the treatment of choice, with laparoscopic anatomical resection being a good treatment option for this small tumor.

Clip on Staple Method to Prevent Bile Leakage in Anatomical Liver Resection Using Stapling Devices.

BACKGROUND/AIM: Bile leakage after liver surgery is still a problem to be solved. Here, we introduce a simple new technique, the Clip on Staple method, a preventive measure for bile leakage after anatomical liver resection using a stapling device. PATIENTS AND METHODS: Before liver parenchymal transection, the roots of Glissonean pedicles for target segments were dissected and divided using the Endo-GIA™ Tri-Staple™ Curved Tip. After the parenchymal transection was completed, the full length of the stapled stump was reinforced by multiple clips. The DS Titanium Ligation Clip was used as the clipping device. RESULTS: Twenty patients underwent this technique during anatomical liver resections with stapling devices. No patient developed postoperative bile leakage of any grade. There was no reoperation or readmission within 90 days. CONCLUSION: The Clip on Staple method is simple and offers a preventive effect for postoperative bile leakage after anatomical liver resection using stapling devices.

Clip on Staple Method Reduces Clinically Relevant Pancreatic Fistula After Distal Pancreatectomy.

BACKGROUND/AIM: In order to overcome postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP), we have developed a new simple technique-Clip on Staple method. PATIENTS AND METHODS: In Clip on Staple method, pancreatic parenchyma was divided using a stapling device with a stepped-height staple design to make linear compression line, and thereafter, the full length of the staple line was reinforced by multiple clips. Clinical outcomes were retrospectively compared between Clip on Staple group (n=23) and Non-Clip group (n=38). RESULTS: The incidence of clinically relevant POPF (CR-POPF) was significantly lower in the Clip on Staple group than in the Non-Clip group (4.3 and 36.8%, p=0.005). Multivariate logistic regression analysis revealed that only Clip on Staple method was an independent predictive factor of a decrease in the occurrence of CR-POPF. CONCLUSION: The Clip on Staple method, a simple and easily applicable technique even in laparoscopic surgery, significantly reduced the occurrence of CR-POPF among patients undergoing DP.

Pure pancreatic hepatoid carcinoma: a surgical case report and literature review.

BACKGROUND: Hepatoid carcinoma (HC) is an extra-hepatic neoplasm that shares the morphological and immunohistochemical features of hepatocellular carcinoma. Pancreatic HC exists as either pure or combined type. Pure pancreatic HC is extremely rare, with only a few cases reported in the literature to date. Because of the rarity of pure pancreatic HC, its clinical features including incidence, behavior, and prognosis remain unclear. We herein report the case of a 56-year-old man who developed pure pancreatic HC treated with surgical resection. We also include a review of the existing literature. CASE PRESENTATION: A 56-year-old male patient was admitted to our hospital after a pancreatic cyst was identified by abdominal ultrasonography on a comprehensive medical examination. Endoscopic ultrasound revealed a cystic mass measuring 13 mm in size in the pancreatic head and a low-density mass measuring 16 mm in size in the pancreatic tail, which was partially enhanced on contrast-enhanced ultrasound. Contrast-enhanced computed tomography (CT) revealed a branch duct type intraductal papillary mucinous neoplasm in the pancreatic head and an early enhanced nodule measuring approximately 10 mm in size in the pancreatic tail. Endoscopic ultrasound-guided fine-needle aspiration of the hypervascular tumor was performed. The hypervascular tumor was suspected to be a solid pseudopapillary neoplasm. Laparoscopic spleen-preserving distal pancreatectomy was performed. Histology was identical to hepatocellular carcinoma of the liver. Immunohistochemically, the tumor cells were positive for hepatocyte paraffin 1, and a canalicular pattern was confirmed on the polyclonal carcinoembryonic antigen staining. The patient was diagnosed with a moderately differentiated pancreatic HC. The patient was followed up without adjuvant chemotherapy, and there was no evidence of recurrence at 6 months post-operatively. CONCLUSIONS: We present a case of moderately differentiated pure pancreatic HC. For the accurate preoperative diagnosis of pure pancreatic HC, biopsy is preferred to cytology or preoperative imaging studies such as CT. The prognosis of pure pancreatic HC depends on its differentiation.

Prognostic impact of programmed cell death 1 ligand 1 expression in human leukocyte antigen class I-positive hepatocellular carcinoma after curative hepatectomy.

BACKGROUND: Hepatocellular carcinoma (HCC) is one of the most common solid tumors worldwide. Surgery is potentially curative, but high recurrence rates worsen patient prognosis. The interaction between the proteins programmed cell death 1 (PD-1) and programmed cell death 1 ligand 1 (PD-L1) is an important immune checkpoint. The significance of PD-L1 expression and human leukocyte antigen class I (HLA class I), recognized by CD8 T cells, in the prognosis of patients with HCC remains to be determined. METHODS: We assessed the levels of PD-L1 and HLA class I expression on HCC samples from 80 patients who had undergone hepatectomy at our institution, and evaluated the correlations between PD-L1 and HLA class I expression and patient prognosis. RESULTS: High HLA class I expression was correlated with significantly better recurrence-free survival (RFS), but not overall survival (OS). Multivariate analysis showed that high HLA class I expression was an independent predictor of improved RFS. Low expression of PD-L1 on HCC tended to predict better OS, but the difference was not statistically significant. PD-L1 expression on HCC correlated with the number of CD163-positive macrophages and HLA class I expression with CD3-positive cell infiltration. Univariable and multivariable analyses showed that combined PD-L1 low/HLA class I high expression on HCCs was prognostic for improved OS and RFS. CONCLUSIONS: PD-L1 status may be a good predictor of prognosis in HCC patients with high HLA class I expression. Novel therapies targeting the PD-L1/PD-1 pathway may improve the prognosis of patients with HCC.

Glasgow Prognostic Score (GPS) can be a useful indicator to determine prognosis of patients with colorectal carcinoma.

The Glasgow Prognostic Score (GPS), an inflammation-based score, has been used to predict the biologic behavior of malignant tumors. The aim of the current study was to elucidate a further significance of GPS in colorectal carcinoma. Correlation of GPS and modified GPS (mGPS), which are composed of combined score provided for serum elevation of C-reactive protein and hypoalbuminemia examined before surgical treatment, with clinicopathologic features was investigated in 272 patients with colorectal carcinoma. Survival of GPS 1 patients was significantly worse than that of GPS 0 patients (P= 0.009), and survival of GPS 2 patients was significantly worse than that of GPS 1 patients (P < 0.0001). Similarly, survival of mGPS 1 patients was significantly worse than that of mGPS 0 patients (P = 0.009), and survival of mGPS 2 patients was significantly worse than that of mGPS 1 patients (P = 0.0006). Multivariate analysis demonstrated that GPS (P < 0.0001) as well as tumor stage (P= 0.004) and venous invasion (P = 0.011) were factors independently associated with worse prognosis. Both GPS and mGPS could classify outcome of patients with a clear stratification, and could be applied as prognostic indicators in colorectal carcinoma.

Arachidonic acid induces direct interaction of the p67(phox)-Rac complex with the phagocyte oxidase Nox2, leading to superoxide production.

The phagocyte NADPH oxidase Nox2, heterodimerized with p22(phox) in the membrane, is dormant in resting cells but becomes activated upon cell stimulation to produce superoxide, a precursor of microbicidal oxidants. Nox2 activation requires two switches to be turned on simultaneously: a conformational change of the cytosolic protein p47(phox) and GDP/GTP exchange on the small GTPase Rac. These proteins, in an active form, bind to their respective targets, p22(phox) and p67(phox), leading to productive oxidase assembly at the membrane. Although arachidonic acid (AA) efficiently activates Nox2 both in vivo and in vitro, the mechanism has not been fully understood, except that AA induces p47(phox) conformational change. Here we show that AA elicits GDP-to-GTP exchange on Rac at the cellular level, consistent with its role as a potent Nox2 activator. However, even when constitutively active forms of p47(phox) and Rac1 are both expressed in HeLa cells, superoxide production by Nox2 is scarcely induced in the absence of AA. These active proteins also fail to effectively activate Nox2 in a cell-free reconstituted system without AA. Without affecting Rac-GTP binding to p67(phox), AA induces the direct interaction of Rac-GTP-bound p67(phox) with the C-terminal cytosolic region of Nox2. p67(phox)-Rac-Nox2 assembly and superoxide production are both abrogated by alanine substitution for Tyr-198, Leu-199, and Val-204 in the p67(phox) activation domain that localizes the C-terminal to the Rac-binding domain. Thus the "third" switch (AA-inducible interaction of p67(phox)·Rac-GTP with Nox2) is required to be turned on at the same time for Nox2 activation.

Prognostic criteria in colorectal carcinoma constructed by the combination of tumor-related and host-related factors.

BACKGROUND: The significance of prognostic criteria based on a combination of tumor-related and host-related factors for patients with colorectal carcinoma has not been appreciated fully. METHODS: Correlation of tumor-related and host-related score (TRHRS), which are constructed by the combination of serum elevation of C-reactive protein and pathologic lymph node metastasis (scores ranging 0 to 2), with clinicopathologic features including prognosis was studied in 271 patients with colorectal carcinoma who had been treated with curative resection. RESULTS: Significant difference regarding survival was observed both between TRHRS 0 and 1 (P = .028) and between TRHRS 1 and 2 (P < .0001). Multivariate analysis showed that histologic types (P = .040) and TRHRS (P < .0001) were independent prognostic indicators. CONCLUSION: Criteria for the prediction of prognosis in colorectal carcinoma treated with curative resection based on both tumor-related and host-related factors could provide a strict stratification.

Three-dimensional computed tomography analysis of variations in the middle hepatic vein tributaries: proposed new classification.

PURPOSE: To evaluate the anatomical variations in the middle hepatic vein tributaries (V5/V8) for determining the reconstruction strategy in right lobe living donor liver transplantation (LDLT). METHODS: The V5/V8 variations were examined in 268 patients and were classified into three and two types, respectively. The reconstruction rate (RR), patency rate (PR) and clinical outcomes were retrospectively evaluated in 46 right lobe LDLT cases. RESULTS: In terms of V5 variations, the RR and PR were significantly higher for type 2 than type 3 (82.6 vs. 44.4 % and 73.7 vs. 25.0 %, respectively). The alanine aminotransferase level on postoperative day (POD) 5 in the V5 patent group was significantly lower than in the occluded group (123 vs. 191 IU/dL). Regarding V8 variations, the RR and PR were significantly higher for type 1 than type 2 (44.4 vs. 17.6 % and 75.0 vs. 33.3 %, respectively). The aspartate aminotransferase level on POD 3 was significantly lower in the V8 patent group than in the occluded group (50 vs. 121 IU/dL). CONCLUSION: For right lobe grafts with single large V5 (type 2) or V8 (type 1) variations, reconstruction is necessary. Our new classification of the MHV tributaries is useful for determining the reconstruction strategy to use in right lobe LDLT.

Strategic breakthrough in adult ABO-incompatible living donor liver transplantation: preliminary results of consecutive seven cases.

ABO-incompatibility is a major obstacle to expanding exiguous donor pools in adult liver transplantation, especially in countries where grafts from deceased donors are uncommon. We present our preliminary results of ABO-incompatible (ABO-I) adult living donor liver transplantation (LDLT) using a new, simple protocol. Seven consecutive cases of ABO-I LDLT were managed by the same protocol including pre-operative administration of a single dose of rituximab (375 mg/m(2) ) followed by three to five sessions of plasma exchange before LDLT without portal infusion therapy. The triple immunosuppression protocol consisted of tacrolimus, mycophenolate mofetil and steroids, with mycophenolate mofetil starting seven d before LDLT. Splenectomy was performed for all cases. All patients are alive (100% survival) with a mean follow-up of 852 d (715-990 d). Neither antibody-mediated nor hyperacute rejection were encountered. There was only one episode of mild acute cellular rejection, for which steroid augmentation was effective. The median preformed isoagglutinin antibody titer before plasma exchange was 256, while the median antibody titer immediately before LDLT was 16. In conclusion, adult ABO-I LDLT results were excellent - comparable or even superior to those of ABO-compatible LDLT. ABO-I adult LDLT has now become a more applicable modality without the need for an appropriate donor.

Nutrition support and infections associated with hepatic resection and liver transplantation in patients with chronic liver disease.

Malnutrition is common in liver cirrhotic patients who will undergo liver resection or liver transplantation. A precise evaluation of their nutrition status is thus difficult because of the presence of ascites and the edema caused by their impaired protein synthesis. Both perioperative enteral and parenteral nutrition have benefits in reducing the morbidity and mortality of liver surgery, and in general, oral nutrition supplements are recommended. Branched-chain amino acids (BCAAs) promote protein and glycogen synthesis and regulate immune system function. Synbiotics, a combination of pro- and prebiotics, is reported to enhance immune responses. Oral nutrition support with BCAAs, synbiotics, and an immune-enhancing diet have a beneficial effect on preventing the perioperative infections associated with hepatic resection or liver transplantation.

Relevance of HLA compatibility in living donor liver transplantation: the double-edged sword associated with the patient outcome.

HLA compatibility in living donor liver transplantation (LDLT) seems relevant to the acceptability of graft livers because LDLT recipients often share most or some part of HLAs with the respective donors. This study retrospectively investigated whether HLA compatibility affected the outcome of LDLT. Three hundred ninety LDLTs were performed in this hospital, and 346 pairs of HLAs (HLA-A, B, DR) were retrieved from the medical record between October 1996 and March 2011. The dates of the deaths were censored when a recipient apparently died of or was retransplanted by other causes than graft failure because of host-versus-graft (HVG) response to purely analyze the outcomes of LDLT in view of HVG response. The relationship between HLA compatibility and graft-versus-host disease (GVHD) was also analyzed. No recipients with recipient-against-donor HLA mismatch (R→D MM) 0 experienced graft failure by HVG response. On the other hand, three of five recipients with "R→D MM 0" together with "donor-against-recipient MM 3" died of fatal GVHD. HLA compatibility in LDLT not only affected the long-term acceptance of graft livers but also the risk of fatal GVHD.

Etiologies, risk factors, and outcomes of bacterial pneumonia after living donor liver transplantation.

The prevalence and clinical characteristics of bacterial pneumonia after living donor liver transplantation (LDLT) have not yet been elucidated. We performed a retrospective analysis of 346 LDLT recipients. Fifty patients (14.5%) experienced bacterial pneumonia after LDLT, and they had a higher short-term mortality rate (42.0%) than patients with other types of bacterial infections after LDLT. Gram-negative bacteria accounted for 84.0% of the causative pathogens. A multivariate analysis showed that preoperative diabetes (P < 0.01), United Network for Organ Sharing status 1 or 2A (P < 0.01), and an operative blood loss > 10 L (P = 0.03) were significant risk factors for bacterial pneumonia after LDLT. Post-LDLT pneumonia was associated with the following post-LDLT events: the prolonged use of mechanical ventilation (≥3 days), a prolonged stay in the intensive care unit (≥7 days), the creation of a tracheostomy, primary graft dysfunction, the use of mycophenolate mofetil, and the need for renal replacement therapy. Among patients with bacterial pneumonia, the mortality rate was higher for patients with delayed-onset pneumonia, which occurred at least 10 days after transplantation (n = 15), and it was significantly associated with graft dysfunction. A combination of broad-spectrum antibiotics and aminoglycosides provided cover for most gram-negative bacteria except Stenotrophomonas maltophilia, which was associated with a longer period of mechanical ventilation and was resistant to commonly used broad-spectrum antibiotics. Delayed-onset bacterial pneumonia is a serious type of bacterial infection after LDLT and is frequently associated with graft dysfunction. The multidrug resistance of S. maltophilia is an issue that needs to be addressed.

Factors linked to longterm survival of patients with hepatocellular carcinoma accompanied by tumour thrombus in the major portal vein after surgical resection.

OBJECTIVES: The prognosis in patients with hepatocellular carcinoma (HCC) accompanied by main portal vein tumour thrombus (MPVTT) is poor. The aim of this study was to clarify the factors linked to survival of >5 years after hepatectomy in HCC patients with MPVTT. METHODS: Twenty-nine HCC patients with MPVTT were divided into two groups comprising, respectively, patients who survived >5 years after hepatectomy (survivors, n= 5) and those who did not (non-survivors, n= 24). The two groups were compared. RESULTS: Overall survival rates at 1, 3 and 5 years were 62.1%, 24.1% and 17.2%, respectively. Four (80.0%) 5-year survivors had recurrences of HCC in which the number of recurrent nodules was under four. Three (21.4%) of the 14 non-survivors who underwent curative resection experienced recurrences of HCC and all of them demonstrated fewer than four recurrent nodules (P= 0.0114). Local therapy, such as radiofrequency ablation and resection of recurrence, had more often been used in survivors than in non-survivors (P= 0.0364). CONCLUSIONS: Although surgical outcomes in patients with HCC accompanied by MPVTT are unsatisfactory, some patients do enjoy longterm survival. When the number of recurrent nodules is less than four, local therapy should be selected with the aim of achieving 5-year survival.

Acoustic radiation force impulse imaging predicts postoperative ascites resulting from curative hepatic resection for hepatocellular carcinoma.

BACKGROUND: Measurement of liver stiffness using Virtual Touch Tissue Quantification (VTTQ) based on acoustic radiation force impulse imaging reflects the degree of hepatic fibrosis and reserve. This prospective study investigated how well the VTTQ value predicts the development of postoperative complications before curative hepatic resection for hepatocellular carcinoma (HCC). METHODS: The study enrolled 50 consecutive patients between February 2009 and October 2010 whose preoperative VTTQ values were determined before they underwent curative hepatic resection for HCC. We assessed the relationship between postoperative complications and VTTQ values. RESULTS: The study included 41 (82%) patients with chronic hepatitis and 9 (18%) with nonviral cirrhosis. The mean VTTQ value was 1.60 (m/sec), which correlated with the fibrosis stage (P = .0058). The VTTQ value was the only variable correlated with postoperative ascites that did not respond to pharmacologic treatment and required invasive management. Univariate and subsequent multivariate analyses revealed that the preoperative VTTQ value was the only independent risk factor for predicting the development of postoperative ascites (cutoff, 1.68 cm/sec; P = .007; odds ratio, 76.481). The area under the receiver operating characteristic curve for the diagnosis of postoperative ascites using VTTQ values was 0.90, whereas those using the aspartate transaminase-to-platelet ratio index and indocyanine green retention rate at 15 minutes values were 0.68 and 0.55, respectively. CONCLUSION: These data suggest that the VTTQ value is a reliable surrogate marker for predicting postoperative ascites before curative hepatic resection for HCC.

Role of tumor-associated macrophages in the progression of hepatocellular carcinoma.

Recent studies have shown that the tumor microenvironment plays an important role in cancer progression. Tumor-associated macrophages (TAMs), in particular, have been found to be associated with tumor progression. Macrophages have multiple biological roles, including antigen presentation, target cell cytotoxicity, removal of foreign bodies, tissue remodeling, regulation of inflammation, induction of immunity, thrombosis, and endocytosis. Recent immunological studies have identified two distinct states of polarized macrophage activation: the classically activated (M1) and the alternatively activated (M2) macrophage phenotypes. Bacterial moieties such as lipopolysaccharides and the Th1 cytokine interferon-γ polarize macrophages toward the M1 phenotype. The M2 polarization was discovered as a response to the Th2 cytokine interleukin-4. In general, M2 macrophages exert immunoregulatory activity, participate in polarized Th2 responses, and aid tumor progression. TAMs have recently been found to play an important role in hepatocellular carcinoma (HCC) progression. Based on the properties of TAMs, obtained from pathological examination of resected specimens, we have identified new therapeutic approaches, involving the targeting of TAMs with adjuvant therapy after hepatic resection for HCC. This review discusses the roles of TAM in HCC progression and the possibility of new therapies targeting TAMs.

Beneficial effects of supplementation with branched-chain amino acids on postoperative bacteremia in living donor liver transplant recipients.

The aim of this study was to investigate the effects of preoperative oral supplementation with branched-chain amino acids (BCAAs) on postoperative bacteremia after living donor liver transplantation (LDLT) for chronic liver failure. Two hundred thirty-six patients who underwent adult-to-adult LDLT were evaluated in this retrospective study. The patients were divided into 2 groups: those who received oral supplementation with BCAAs before transplantation (the BCAA group; n = 129) and those who did not (the non-BCAA group; n = 107). Before the LDLT indication was determined, BCAA supplementation was prescribed by a hepatologist to preserve hepatic reserves. The clinical characteristics and the incidence of bacteremia were compared between the 2 groups. As for clinical characteristics, the Child-Pugh scores (P = 0.0003) and the Model for End-Stage Liver Disease scores (P = 0.0008) were significantly higher in the BCAA group versus the non-BCAA group. The incidence of bacteremia for Child-Pugh class C patients was significantly lower in the BCAA group (6/90 or 6.7%) versus the non-BCAA group (11/50 or 22.0%, P = 0.0132). In a multivariate analysis, non-BCAA supplementation was an independent risk factor for bacteremia. In conclusion, preoperative BCAA supplementation might reduce the incidence of bacteremia after LDLT. Nevertheless, this is a preliminary report, and further studies, such as randomized, prospective studies, are necessary to clarify the beneficial effects of BCAA supplementation on postoperative bacteremia after liver transplantation.