Routine single-incision laparoscopic common bile duct exploration with concomitant cholecystectomy for elderly patients: a 6-year retrospective comparative study.

BACKGROUND: While single-incision laparoscopic cholecystectomy (SILC) has gained more popularity in recent years, its application to elderly patients needs further evaluation. Few SILC studies regarded this rapidly growing vulnerable population, and single-incision laparoscopic common bile duct exploration (SILCBDE) was never mentioned. We conducted an observational study of 146 routine SILCBDE to address this issue. METHODS: One hundred forty-six consecutive patients underwent SILCBDE with concomitant cholecystectomies during a period of 6 years (July 2012-June 2016 and July 2018-July 2020). Forty patients with an age of 65 years or older were the study target. Characteristics and operative outcomes were compared with the remaining 106 younger patients by retrospective chart review. The primary outcomes include complications and mortality, while the secondary outcomes contain intraoperative blood loss, operative time, procedural conversions, postoperative length of hospital stay, and bile duct stone recurrence. RESULTS: There was no mortality. The bile duct stone clearance rate was 98.6%. The elderly group had higher American Society of Anesthesiologists (ASA) scores, higher comorbidity rate, higher acute cholangitis rate, lower completion intraoperative cholangiography (IOC) rate, longer operative time, more blood loss, longer postoperative hospital stay (p < .001), longer total hospital stay (p < .001), higher procedural conversion rate (p < .05), higher complication rate (p < .001), and the exclusive open conversion (2.5%). The difference in complications derived from Clavien-Dindo grade I. CONCLUSION: Routine SILCBDE with concomitant cholecystectomy by experienced surgeons is safe and efficacious for elderly patients as for younger patients. Randomized controlled trials are anticipated.

A mass spectrometry imaging and lipidomic investigation reveals aberrant lipid metabolism in the orthotopic mouse glioma.

Lipids perform multiple biological functions and reflect the physiology and pathology of cells, tissues, and organs. Here, we sought to understand lipid content in relation to tumor pathology by characterizing phospholipids and sphingolipids in the orthotopic mouse glioma using MALDI MS imaging (MSI) and LC-MS/MS. Unsupervised clustering analysis of the MALDI-MSI data segmented the coronal tumoral brain section into 10 histopathologically salient regions. Heterogeneous decrease of the common saturated phosphatidylcholines (PCs) in the tumor was accompanied by the increase of analogous PCs with one or two additional fatty acyl double bonds and increased lyso-PCs. Polyunsaturated fatty acyl-PCs and ether PCs highlighted the striatal tumor margins, whereas the distributions of other PCs differentiated the cortical and striatal tumor parenchyma. We detected a reduction of SM d18:1/18:0 and the heterogeneous mild increase of SM d18:1/16:0 in the tumor, whereas ceramides accumulated only in a small patch deep in the tumoral parenchyma. LC-MS/MS analyses of phospholipids and sphingolipids complemented the MALDI-MSI observation, providing a snapshot of these lipids in the tumor. Finally, the proposed mechanisms responsible for the tumoral lipid changes were contrasted with our interrogation of gene expression in human glioma. Together, these lipidomic results unveil the aberrant and heterogeneous lipid metabolism in mouse glioma where multiple lipid-associated signaling pathways underline the tumor features, promote the survival, growth, proliferation, and invasion of different tumor cell populations, and implicate the management strategy of a multiple-target approach for glioma and related brain malignancies.

Health care needs of elderly patients with lung, liver, or colon cancer in Taiwan.

BACKGROUND: Globally, different age groups in the elderly population have experienced major shifts over time. Human life expectancy doubled from the 19th to the twentieth century and has increased to 80 years in the twenty-first century. These conditions imply economic challenges and the increasing prevalence of certain health conditions. Old age is associated with increased care needs in various aspects of daily life. This study assessed the health care needs of elderly patients with lung, liver, and colorectal cancer in Taiwan and analyzed the factors underlying their needs. METHODS: This cross-sectional descriptive survey assessed 234 elderly patients with diagnosis of lung, liver, and colorectal cancer in Taiwan. We investigated their health care needs and daily living functions by using the Supportive Care Needs Survey and Karnofsky Performance Status, respectively. RESULTS: Patients required the most assistance in physical functioning and daily living. Patients aged ≥85 years required more care than those aged 65-74 years in terms of information access and sexuality needs. Patients with poor functional status required more care than those capable of undertaking normal activities. Patients diagnosed as having liver cancer required more care than those with lung or colorectal cancer. Patients with advanced cancer required more physical and daily care than those with early-stage cancer. CONCLUSIONS: Patients' health care needs differed with age, primary cancer site, and functional status. Patients aged ≥85 years and those with poor function, primary liver cancer, and advanced cancer had higher care needs.

The Expression Profile and Prognostic Significance of Metallothionein Genes in Colorectal Cancer.

Colorectal cancer (CRC) is a heterogeneous disease resulting from the combined influence of many genetic factors. This complexity has caused the molecular characterization of CRC to remain uncharacterized, with a lack of clear gene markers associated with CRC and the prognosis of this disease. Thus, highly sensitive tumor markers for the detection of CRC are the most essential determinants of survival. In this study, we examined the simultaneous downregulation of the mRNA levels of six metallothionein (MT) genes in CRC cell lines and public CRC datasets for the first time. In addition, we detected downregulation of these six MT mRNAs' levels in 30 pairs of tumor (T) and adjacent non-tumor (N) CRC specimens. In order to understand the potential prognostic relevance of these six MT genes and CRC, we presented a four-gene signature to evaluate the prognosis of CRC patients. Further discovery suggested that the four-gene signature (MT1F, MT1G, MT1L, and MT1X) predicted survival better than any combination of two-, three-, four-, five-, or six-gene models. In conclusion, this study is the first to report that simultaneous downregulation of six MT mRNAs' levels in CRC patients, and their aberrant expression together, accurately predicted CRC patients' outcomes.

Antiplatelet Activity of a Newly Synthesized Novel Ruthenium (II): A Potential Role for Akt/JNK Signaling.

In oncotherapy, ruthenium complexes are considered as potential alternatives for platinum compounds, and have been proved as promising anticancer drugs with high efficacy and lesser side effects. Platelet activation plays a major role in cancer metastasis and progression. Hence, this study explored the effect of a newly synthesized ruthenium complex, [Ru(η6-cymene)(L)Cl]BF4(TQ5), where L = 4-phenyl-2-pyridin-2-yl-quinazoline), on human platelet activation. TQ5 (3-5 µM) inhibited concentration-dependent collagen-induced platelet aggregation in washed human platelets. However, this compound only inhibited platelet aggregation at a maximum concentration of 500 and 100 µM against thrombin and 9,11-dideoxy-11α, 9α-epoxymethanoprostaglandin (U46619)-induced stimulation, respectively. TQ5 inhibited collagen-induced ATP release and calcium mobilization ([Ca2+]i), without inducing cell cytotoxicity. In addition, neither SQ22536, an adenylate cyclase inhibitor, nor 1H-[1,2,4] oxadiazolo [4,3-a]quinoxalin-1-one (ODQ), a guanylate cyclase inhibitor, significantly reversed the TQ5-mediated inhibition of platelet aggregation. TQ5 inhibited the collagen-induced phosphorylation of protein kinase B (Akt) and c-Jun N-terminal kinase (JNK), but did not effectively inhibit extracellular signal-regulated kinase 1/2 (ERK1/2) and p38-mitogen-activated protein kinase (p38-MAPK) in human platelets. Additionally, TQ5 significantly prolonged the closure time in whole blood and increased the occlusion time of thrombotic platelet plug formation in mice. This study demonstrates, for the first time, that a newly synthesized ruthenium complex, TQ5, exhibits potent antiplatelet activity by hindering ATP release and [Ca2+]i, and by decreasing the activation of Akt/JNK signals. Together, these results suggest that TQ5 could be developed as a therapeutic agent that helps prevent or treat thromboembolic disorders, since it is found to be potently more effective than a well-established antithrombotic aspirin.

Single center experience with ALPPS and timing with stage 2 in patients with fibrotic/cirrhotic liver.

Associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) is a novel procedure for major resection in patients with insufficient future liver remnant (FLR). Effective FLR augmentation is pivotal in the completion of ALPPS. Liver fibrosis/cirrhosis associated with chronic viral hepatitis impairs liver regeneration. To investigate the augmentation of FLR in associating ALPPS between patients with fibrotic/cirrhotic livers (FL) and non-fibrotic livers (NFL) and compare their short-term clinical outcomes and long-term survival. Patients were divided into two groups based on the Ishak modified staging: non-fibrotic liver group (NFL, stage 0) and fibrotic/cirrhotic liver group (FL, stage 1-5/6). Weekly liver regeneration in FLR, perioperative data, and survival outcomes were investigated. Twenty-seven patients with liver tumors underwent ALPPS (NFL, n = 7; FL, n = 20). NFL and FL patients had viral hepatitis (28.6% [n = 2] and 95% [n = 19]), absolute FLR volume increments of 134.90 ml and 161.85 ml (p = 0.825), and rates of hypertrophy were 16.46 ml/day and 13.66 ml/day (p = 0.507), respectively. In the FL group, baseline FLR volume was 360.13 ml, postoperatively it increased to a plateau (542.30 ml) in week 2 and declined (378.45 ml) in week 3. One patient (3.7%) with cirrhotic liver (stage 6) failed to proceed to ALPPS-II. The overall ALPPS-related major complication rate was 7.4%. ALPPS is feasible for fibrotic liver patients classified by Ishak modified stages ≤ 5. After ALPPS-I, 14 days for FLR augmentation seems an appropriate waiting time to reach a maximum FLR volume in these patients.

Expression of aquaporins in rat liver regeneration.

OBJECTIVE: The remarkable ability of liver to regenerate after insults has been harnessed by surgeons when designing techniques for liver resection or transplantation. However, the underlying mechanisms of liver regeneration are not fully clarified. On the other hand, aquaporins (AQPs) are small transmembrane proteins with unexpected physiological roles in addition to water transport. For example, they play pivotal roles in cell migration, angiogenesis, and cell proliferation, events that are also occurred during liver regeneration. We thus examined the possible involvement of AQPs in this regenerative process. MATERIAL AND METHODS: A two-thirds partial hepatectomy (PH) rat model was employed. The temporal expression of various AQPs in the liver following PH was determined by semiquantitative reverse transcription polymerase chain reaction (RT-PCR) and Western blotting. The localization of AQPs was evaluated by immunohistochemistry. RESULTS: As anticipated, AQP0, 8, 9, and 11 were detected mainly in hepatocytes; unexpectedly, Kupffer cells were observed to express AQP8 during a specific period of time in the regenerative process. AQP9 protein was shown to be expressed in a progressively enhanced pattern at early time points after PH. A transient expression of AQP11 in the nucleus of hepatocytes was observed. CONCLUSION: These findings suggest the possibility that AQP might be involved in the PH-induced liver regeneration.

Overexpression of AKR1B10 Predicts Poor Prognosis in Gastric Cancer Patients Undergoing Surgical Resection.

Aldo-keto reductase family 1 member B10 (AKR1B10) is associated with several cancers, but the prognostic role in gastric cancer (GC) remains unclear. We enrolled 359 GC patients who underwent a gastrectomy with D2 lymph node dissection. AKR1B10 expression was scored using an immunoreactive scoring system based on immunohistochemistry. Adjuvant chemotherapy with S-1 or oxaliplatin plus capecitabine was administered to pathological stage II or III disease patients. There were 117 (32.6%) and 242 (67.4%) patients with AKR1B10 overexpression and low expression, respectively. Patients overexpressing AKR1B10 had worse 5-year disease-free survival (DFS) and overall survival (OS) rates than those with low expression of AKR1B10. Pathological T3-T4 stage, pathological stage III, lymph node ratio ≥25%, and AKR1B10 overexpression were independent prognostic factors for worse DFS and OS in univariate and multivariate analyses. For 162 stage II or III patients who received adjuvant chemotherapy after surgical resection and 59 patients with signet ring cell carcinoma histology, AKR1B10 overexpression was also associated with inferior DFS and OS. AKR1B10 was not associated with clinical survival in stage I GC patients. In conclusion, AKR1B10 overexpression may be an independent prognostic factor for worse survival in GC patients who underwent gastrectomy with D2 lymph node dissection.

Nursing manpower forecast for cancer patients.

BACKGROUND AND OBJECTIVES: This paper presents a dynamic model aimed at predicting nursing manpower requirements for cancer care over the next ten years. The proposed model, based on the Taiwan Health Insurance Database (2000 to 2010), is meant to serve as a reference in establishing policy for government health units. METHODS: The proposed prediction model uses fuzzy sets to replace definite values with interval values in order to account for uncertainties in real-world data and enhance the flexibility of prediction results. RESULTS: Our results suggest that the demand for nursing manpower for cancer care will grow steadily in the foreseeable future. The gap between the demand for nursing staff and the supply is expected to peak in 2027. By then, the number of oncologists is expected to reach 7,083 (54.32% of the total number of in-hospital physicians), but the number of oncology nurses will be less than 26,297 (56.5% of the total healthcare manpower). It is also expected that there will be fewer than 1,613 outpatient physicians (71.81% of the total number of physicians) and fewer than 4,967 outpatient nurses (68.46% of the total nursing manpower). CONCLUSIONS: This paper provides a valuable reference for government agencies involved in the nursing manpower planning to improve the quality of nursing care.

Cytoreduction surgery and hyperthermic intraperitoneal chemotherapy for treating advanced peritoneal metastases of hepatocellular carcinoma.

BACKGROUND: An effective treatment strategy for peritoneal metastasis (PM) of hepatocellular carcinoma (HCC-PM) has yet to be established. Although cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) have shown favorable outcomes in certain malignancies, their role in peritoneal metastatic HCC is unclear. Herein, we present a series of patients with HCC-PM treated with CRS/HIPEC and evaluate their outcomes. METHODS: Records of patients with HCC-PM who had undergone CRS/HIPEC at the Hyperthermia Center of Yuan's General Hospital, Kaohsiung, Taiwan, between September 2015 and December 2016 were reviewed retrospectively. Patients were followed up until September 2019. We assessed the clinical courses and outcomes of these patients to clarify the benefits of CRS/HIPEC. RESULTS: Six patients were included in our study. HCC-PM occurred synchronously in one patient and occurred metachronously in five patients after therapeutic minimally invasive procedures, including radiofrequency ablation, laparoscopic hepatectomy, robotic hepatectomy or spontaneously. The median peritoneal cancer index was 18.5. All patients experienced complete peritoneal cytoreduction without perioperative mortality. One patient had two CTCAE grade 3 complications. The median follow-up was 16 months. The median overall survival was 15.7 months. Four patients died of lung metastasis or liver failure owing to intrahepatic recurrence. The survival rates observed at 1, 2, and 4 years were 66.7%, 33.3%, and 33.3%, respectively. CONCLUSIONS: CRS followed by HIPEC is feasible in patients with HCC-PM and might provide selected patients a chance for local disease control and longer survival. CRS/HIPEC might be considered as a treatment option in highly selected patients, as part of multimodal therapy approaches.

Antagonizing TGF-beta induced liver fibrosis by a retinoic acid derivative through regulation of ROS and calcium influx.

Transforming growth factor-beta1 (TGF-beta1) mediates the regulation of extracellular matrix via reactive oxygen species (ROS) and calcium influx, both are activators of hepatic stellate cells (HSC) which play a critical role in hepatic fibrogenesis. Hence one can use ROS assay as the main screening tool for molecules that might antagonize the process of liver fibrosis. A retinoic acid derivative isolated from the mycelium of Phellinus linteus that down-regulates ROS generation and calcium influx in HSC-T6 cells was thus obtained in our screening process. The retinoic acid derivative also reverses an early liver fibrosis, as assayed by liver contents of hydroxyproline, alpha-smooth muscle actin (alpha-SMA), and collagen 1A2, in an early liver fibrosis model we established previously where an inducible expression vector containing a TGF-beta gene was hydrodynamically transferred into a testing animal. Retinoic acid derivative thus acts both in vitro and in vivo to prevent liver fibrosis at an early phase.

Inhibition of transforming growth factor-beta-induced liver fibrosis by a retinoic acid derivative via the suppression of Col 1A2 promoter activity.

Transforming growth factor-beta1 (TGF-beta1) mediates expression of collagen 1A2 (Col 1A2) gene via a synergistic cooperation between Smad2/Smad3 and Sp1, both act on the Col 1A2 gene promoter. In our previous study, we reported that a retinoic acid derivative obtained from Phellinus linteus (designated PL) antagonizes TGF-beta-induced liver fibrosis through regulation of ROS and calcium influx. In this continuing study we seek further the effect of PL on the Smad signaling pathway. We used a Col 1A2 promoter-luciferase construct to study the action of PL on Smad through TGF-beta. We found that PL decreases the promoter activity of Col 1A2, hinders the translocalization of phosphorylated Smad2/3-Smad 4 complex from cytosol into nucleus and inhibits Sp1 binding activity. These results suggest that PL inhibits TGF-beta1-induced Col 1A2 promoter activity through blocking ROS and calcium influx as well as impeding Sp1 binding and translocalization of pSmad 2/3-Smad4 complex into nucleus.

Establishment of an early liver fibrosis model by the hydrodynamics-based transfer of TGF-beta1 gene.

BACKGROUND: Liver fibrosis represents a significant and severe health care problem and there are no efficient drugs for therapy so far. Preventing the progression of fibrogenesis and revival endogenous repair activities is an important strategy for both current and future therapies. Many studies of liver fibrosis consist of animal testing with various hepatotoxins. Although this method is often used, the model at which cirrhosis or extensive fibrosis becomes irreversible has not been well defined and is not representative of early-stage fibrogenesis. We here report the establishment of a transient and reversible liver fibrosis animal model which may better represent an early and natural fibrotic event. We used a high-speed intravenous injection of naked plasmid DNA of transforming growth factor-beta1 (TGF-beta1) gene which is under the control of a metallothionein-regulated gene in a pPK9A expression vector into the tail vein (the hydrodynamics-based transfer) and fed the mouse with zinc sulfate (ZnSO4)-containing water simultaneously. RESULTS: Using our hydrodynamics-based gene transfer model we found that upon induction by ZnSO4, the serum TGF-beta1 level in Balb/c mice and Sp1 transcription factor binding activity peaked at 48 h and declined thereafter to a normal level on the 5th day. In addition, mRNA and protein levels of TGF-beta1 in the liver were also upregulated at 48 h. Furthermore, induction of TGF-beta1 increased the alpha-smooth muscle actin (alpha-SMA), p-Smad2/3, hydroxyproline and collagen 1A2 (Col 1A2) levels in the liver, suggesting a significant liver fibrosis. CONCLUSION: Our results show that TGF-beta1 in pPK9a-transferred mice liver with ZnSO4 feeding can achieve a high expression level with significant fibrosis. However, since TGF-beta1 induction is transient in our model, the fibrotic level does not reach a large scale (panlobular fibrosis) as seen in the CCl4-treated liver. Our model hence represents a dynamic and reversible liver fibrosis and could be a useful tool for studying early molecular mechanism of fibrogenesis or screening of antifibrotic drugs for clinical use.

Prevention of TGF-ß-induced early liver fibrosis by a maleic acid derivative anti-oxidant through suppression of ROS, inflammation and hepatic stellate cells activation.

Current anti-fibrotic effect of antioxidants in vivo is disappointing due probably to the fact that once liver fibrogenesis is established it is too advanced to be reversed by anti-oxidation mechanism. We consider antioxidant may only act on the early phase of fibrogenesis. Thus, we had previously established an early liver fibrosis animal model using an inducible expression vector (pPK9a), which contains TGF-ß gene and was hydro-dynamically transferred into mice to induce a transient liver fibrosis. TGF-ß1 has been well documented to up-regulate the expression of α2(1) collagen (Col 1A2) gene in the liver via the reactive oxygen species (ROS); the process triggers inflammation, leading to hepatic stellate cells (HSC) activation and liver fibrogenesis. Using our animal model and ROS, cyclooxygenase-2 (Cox-2) and Col 1A2 promoter assays as screening targets, we report here that a maleic acid derivative isolated from the Antrodia camphorata mycelium strongly decreases ROS production, promoter activity of Cox-2 and Col 1A2, intracellular calcium, expression of alpha-smooth muscle actin (α-SMA), Smad4-p-Smad2/3 co-localization in cell nucleus and the DNA binding activity of Sp1. Our results suggest that the maleic acid derivative prevents liver fibrosis at an early phase both in vitro and in vivo through the inhibition of ROS, inflammation and the activation of HSC.

Epidemiologic trends in nosocomial bacteremia in a neonatal intensive care unit.

The primary goal of this study was to analyze the epidemiologic features of nosocomial bloodstream infection (NBSI) in a neonatal intensive care unit over a 7-year period. All neonatal patients with NBSI treated from January 1997 to December 2003 were retrospectively analyzed. 232 NBSI episodes were diagnosed in 208 patients. The average NBSI patient-day rates were 4.69 and 2.59 per 1000 patient-days in 1997-1999 and 2000-2003, respectively. The average NBSI rates were 5.00 and 1.50 per 1000 patient days in neonates <1500 g and > or =1500 g, respectively. The proportion of Gram-positive organisms increased from 24% in 1997-2001 to 41% in 2002-2003, whereas the proportion of Gram-negative isolates decreased from 65% in 1997-2001 to 47% in 2002-2003. The implementation of measures for the prevention of nosocomial infection was associated with the reduction of NBSI rates. Low birth weight was demonstrated to be a significant risk factor for NBSI. The fact that Gram-positive organisms were isolated in increasing frequency may impact on the appropriate selection of empiric antimicrobial therapy for NBSI in the neonatal intensive care unit.

Monotherapy with meropenem versus combination therapy with ceftazidime plus amikacin as empirical therapy for neutropenic fever in children with malignancy.

Fifty-four pediatric cancer patients with a total of 100 febrile neutropenic episodes treated at China Medical College Hospital were randomized to receive meropenem or ceftazidime plus amikacin from January 2001 to April 2002. The characteristics of 76 assessable febrile episodes (39 with meropenem and 37 with ceftazidime plus amikacin) were compared between the 2 groups. The success rate with unmodified therapy was not significantly different between the meropenem group (72%) and the ceftazidime-plus-amikacin group (57%). The incidence of side effects was similar between the 2 groups and these side effects were reversible. Microbiologically documented infection, clinically documented infection, and unexplained fever accounted for 35%, 37%, and 28% of episodes, respectively. The clinical response rates in subgroups of documented infection and unexplained fever did not significantly differ between the 2 treatment groups. Meropenem was significantly more effective than ceftazidime plus amikacin in children at high risks of developing severe infection who had profound neutropenia (absolute neutrophil count [ANC] < 100/mm3), prolonged neutropenia (ANC < 500/mm3 lasting for > 10 days), or clinically deteriorating shock (p=0.045). As an empirical treatment, meropenem seems to be as effective and safe as ceftazidime plus amikacin for febrile episodes in children with cancer and neutropenia. Meropenem is more effective for pediatric cancer patients at the high risk of severe infection.

Effect of thalidomide on the expression of vascular endothelial growth factor in a rat model of liver regeneration.

Liver regeneration is an angiogenesis-associated phenomenon. The present study investigated the influence of thalidomide, an antiangiogenic agent, on vascular endothelial growth factor (VEGF) expression and liver regeneration after 70% partial hepatectomy (PH) in rats. PH was performed on 50 rats dosed with either thalidomide (100 mg/kg) or a vehicle (controls) by intragastric administration. Serial changes in hepatic microcirculation were evaluated by laser Doppler flowmetry. The VEGF expression in liver tissue was assessed by immunohistochemical study and western blot analysis. Following hepatectomy, the liver regeneration rate increased markedly and reached a peak at 96 h in the two groups. Thalidomide did not affect the overall restoration of liver mass, although a delay in cell proliferation was observed. Prior to PH, the liver microcirculation in rats treated with thalidomide for 2 days was comparatively less than that in their corresponding controls; however, no significant difference between the groups was detected at any time-point following PH. Western blotting showed that the expression of VEGF was upregulated by hepatectomy and the expression levels in the two groups were equal at all studied time-points. The immunohistochemical staining revealed a waved pattern of VEGF expression which advanced from the periportal to pericentral area in both groups, but a slower advancement was detected in thalidomide-treated rats. In conclusion, thalidomide exerted no significant effects on the expression of VEGF and did not impair the overall restoration of liver mass in a rat model of PH-induced liver regeneration, providing supportive evidence for its use as an adjunct treatment modality for liver cancers.

Primary hepatic carcinoid tumor: a case report and review of the literature.

BACKGROUND: Primary hepatic carcinoid tumor (PHCT) is very rare and difficult to diagnose before biopsy or operation. We report a patient with a small PHCT and review cases in the literature. CASE PRESENTATION: A 48-year-old Chinese female with underlying hepatitis B virus (HBV) infection was found to have a low echoic hepatic nodule by abdominal ultrasound. Tumor markers were negative. Dynamic liver computed tomography scans showed enhancement of the nodule in the arterial phase and early washout in the portal phase. Hepatocellular carcinoma (HCC) was considered based on the image findings and underlying HBV infection. However, the tumor biopsy revealed a malignant neoplasm that originating from neuroendocrine cells. Pre-operative and intra-operative investigations for the possible other origin of carcinoid tumor were negative, so PHCT was confirmed. CONCLUSION: A small and asymptomatic PHCT is extremely rare. PHCT should be one of the differential diagnoses in patients with small hepatic tumor, even in regions with high prevalence of HBV infection and HCC. Pre-operative biopsy is necessary to avoid misdiagnosis even when HCC is highly suspected clinically.

A surgical model of fulminant hepatic failure in rabbits.

AIM: Animal models of fulminant hepatic failure (FHF) have been developed for characterization of disease progression and to evaluate the effectiveness of liver-assist devices, some by treatment with hepatotoxic drugs, viral hepatitis or surgical procedures. We have developed a model in the rabbit by combining resection of the three anterior lobes with ligation of the pedicle of the right lateral lobes, resulting in liver necrosis; the remnant quadrate lobes are left intact. MATERIALS AND METHODS: Adult male New Zealand white rabbits (n=16) were used. Six animals were killed to measure the weight of the separate liver lobes. The others (n=10) underwent left neck central line placement to monitor continuous blood pressure and collect blood for laboratory analysis, and a burr hole on the right parietal bone to monitor the intracranial pressure (ICP). Blood laboratory analysis, clinical hepatic encephalopathy and ICP levels were measured in FHF animals (n=6). Animals (n=4) undergoing a sham operation served as controls. RESULTS: All FHF animals died between 12 and 26 h after liver surgery from FHF characterized by a progressive increase in liver enzymes, ammonia, total bilirubin, coagulopathy, hepatic encephalopathy and intracranial hypertension. Histological features of the ischaemic lobes showed coagulative necrosis of hepatocytes with absence of nuclei and collapse of cell plates. Brain histology revealed hypoxic cell damage. CONCLUSION: We have developed a simple, reproducible model of FHF in rabbits that has a number of features comparable with clinical FHF patients and is well suited for testing experimental bioartificial liver systems and investigating the pathogenesis of FHF.

Improving hepatic and portal venous flows using tissue expander and Foley catheter in liver transplantation.

BACKGROUND AND OBJECTIVE: Vascular reconstruction is important in liver transplantation because its obstruction causes graft failure and eventual loss. Vascular outflow obstruction may be due to graft malposition. We describe our experience with liver allograft repositioning using tissue expander and Foley catheter to improve hepatic and portal venous outflows. PATIENTS AND METHODS: A total of seven patients who received liver transplantation at our institution developed hepatic and/or portal venous obstruction during final graft positioning detected by Doppler ultrasonography (hepatic vein flow <10 cm/s; portal vein flow <12 cm/s). Chart and operative records of these patients were reviewed. Technique of operation, donor-recipient characteristics, use of tissue expander or Foley catheter to improve venous outflow, complications, and outcome were analyzed. RESULTS: Hepatic and/or portal venous obstruction were detected after portal reperfusion. We used commercially available tissue expander used in plastic surgery and Foley catheter to reposition the graft. Tissue expanders were used in three recipients (age: 27-46 yr). Foley catheters were used in four recipients (age: 7 months-53 yr). One recipient used both tissue expander and Foley catheter. Expanders were filled with 300-770 mL saline and placed into the right subphrenic space. Foley catheters were filled with 15-75 mL saline. Significant improvements in hepatic and/or portal venous outflow were detected by Doppler ultrasonography post-graft repositioning. Aspiration of expander and Foley catheter contents was started from 6th to 27th postoperative day under sonographic guidance. All expanders and catheters were removed by the 19th-56th postoperative day (mean: 38 d). Complications included chylous ascites (1/7), bile leak (1/7), tube drain infection (2/7), septicemia (2/7). All complications were successfully managed by non-operative interventions. There was no outflow obstruction detected by ultrasonography before and after removal of expanders and catheters. One- and two-year graft and patient survivals were both 100%. CONCLUSION: The use of tissue expanders and Foley catheters to improve hepatic and portal venous outflow in malposed liver allografts is a simple and safe method after liver transplantation.