Hydrolyzed whey peptide-based diet ameliorates hepatic ischemia-reperfusion injury in the rat nonalcoholic fatty liver.

PURPOSES: The number of patients with nonalcoholic fatty liver disease (NAFLD) is increasing. Hepatic steatosis is a major risk factor for hepatic failure after ischemia-reperfusion (I/R) injury. Hydrolyzed whey peptide (HWP) is a functional liquid-type nutritional diet containing whey peptide, which has previously been shown to exert anti-inflammatory effects. In the present study, we examined the effects of HWP on the hepatic I/R injury in a rat NAFLD model. METHODS: Rats fed a methionine/choline-deficient diet for 4 weeks were divided into two groups after 30 min of whole liver ischemia. In Group-M, HWP was given immediately after reperfusion and every 6 h thereafter. In Group-C, the vehicle was given in the same manner. The liver function tests and microscopic findings of the liver after reperfusion were compared between the two groups. RESULTS: The serum transaminase levels in Group-M were significantly lower than those in Group-C after reperfusion. The gene expression levels of IL-6 and inducible nitric oxide synthase (iNOS) were significantly lower in Group-M compared to Group-C. The TNF-α and uncoupling protein-2 (UCP-2) expression levels were also markedly lower in Group-M. The hepatic necrotic areas in Group-M were significantly smaller than those in Group-C. CONCLUSION: The administration of a HWP diet ameliorated the hepatic I/R injury in rats with NAFLD.

[Pulmonary artery sling and single ventricle treated with a simultaneous operation of slide tracheoplasty, left pulmonary artery reimplantation, and bidirectional cavo-pulmonary shunt].

Pulmonary artery sling is frequently combined with tracheal stenosis, and occasionally combined with congenital heart defects. However, there are few reports of successfully treated cases that were combined with single ventricle. In this article, we report a successfully treated case of pulmonary artery sling combined with tracheal stenosis, single ventricle, pulmonary atresia, vascular ring, and bilateral superior vena cava. A male infant was referred to our hospital for central cyanosis, and was diagnosed with single ventricle (tricuspid stenosis, multiple ventricular septal defect, and hypoplastic right ventricle)with pulmonary atresia by echocardiogram. Tracheal stenosis was shown at cardiac catheterization. Pulmonary artery sling and tracheal diverticulum were diagnosed by computed tomography (CT) and magnetic resonance imaging(MRI)examination. Furthermore, the patient was complicated by vascular ring, which consisted of right aortic arch, an aberrant left subclavian artery, and patent ductus arteriosus, and this ductus arteriosus was connected to the left subclavian artery and pulmonary arterial trunk. After 6 months of medical treatment, including continuous infusion of prostaglandin, re-evaluation was performed by cardiac catheterization. We considered that bidirectional cavo-pulmonary shunt was appropriate for the patient since his pulmonary vasculature had matured well. An operation was performed under the use of cardio-pulmonary bypass. Release of vascular ring by division of the ductus, bilateral bidirectional cavo-pulmonary shunt, and a slide tracheoplasty for tracheal stenosis were performed simultaneously. His recovery was uneventful, and he is currently waiting to receive a Fontan-type operation.

Significance of dihydropyrimidine dehydrogenase and thymidylate synthase mRNA expressions in hepatocellular carcinoma.

AIM: The significance of dihydropyrimidine dehydrogenase (DPD) and thymidylate synthase (TS) gene expressions for the post-surgical prognosis of hepatocellular carcinoma (HCC) has not yet been determined. In the present study, we clarified the significance of DPD and TS gene expressions for the prognosis of HCC. METHODS: Seventy-four patients, who underwent curative hepatic resection for primary HCC, were evaluated. The DPD and TS mRNA levels of the resected HCC specimens were evaluated using a microdissection technique and quantative real-time RT-PCR. The patients were categorized into high and low groups for each mRNA based on the median value. Various clinicopathological factors, including prognosis, and proliferation index using Ki-67 staining were evaluated in association with the DPD and TS mRNA expression levels. RESULTS: The low DPD mRNA expression was related to younger age, advanced clinical stage, undifferentiated histology, and microscopic intrahepatic metastasis. The overall and recurrence-free survival were significantly lower in the low DPD group than in the high DPD group (P < 0.05). Furthermore, the proliferation index in the low DPD group was significantly higher than that in the high DPD group (P < 0.01). On the other hand, the high TS group showed a tendency of better prognosis than the low TS group, although it was not statistically significant. CONCLUSIONS: The low DPD mRNA expression is a significant poor prognostic factor. after curative resection of HCC.

Optimal administration of tacrolimus in reduced-size liver.

The optimal administration of immunosuppressants such as tacrolimus (Tac) for small-for-size (SFS) grafts, where the functional liver mass is small and must regenerate, has not been reported so far. The aim of this study is to clarify the characteristics of Tac metabolism according to liver volume. Seven-week-old male Wistar rats were randomly divided into three groups: (1) Tac administrated and 70% Hx group (Tac 70% Hx group), (2) Tac administrated and 90% Hx group (Tac 90% Hx group), and (3) vehicle administrated and 90% Hx group (control 90% Hx group). In both the Tac groups, Tac (0.3 mg/kg) was given daily for 3 days before operation, and daily after surgery until sacrifice (each time point; n = 5). The plasma concentration of Tac (trough level), as well as liver toxicity, were measured. The plasma concentration of Tac in the Tac 90% Hx group was significantly higher than in the Tac 70% Hx group from 24 to 72 h after operation. Furthermore, expression of CYP3AII mRNA was significantly lower in the Tac 90% Hx group than in the Tac 70% Hx group. Regarding the liver toxicity, there was no significant difference in both the Tac 90% Hx and the control 90% Hx groups. In this experimental study, the plasma concentration of Tac was dependent on the remnant liver volume. Therefore, special attention in regard to Tac administration should also be taken for patients with SFS grafts in living-donor liver transplantation (LDLT).

Real time elastography for noninvasive diagnosis of liver fibrosis.

BACKGROUND/PURPOSE: The accurate preoperative evaluation of liver fibrosis stage is important in determining surgical procedures. Although percutaneous liver biopsy is the gold standard, it may cause undesirable complications, such as bleeding. This study aimed to evaluate the usefulness of real-time tissue elastography for the preoperative assessment of liver fibrosis stage. METHODS: We focused on a new mode of sonogram, real-time elastography, which can show tissue elasticity on images, and express the elasticity numerically. The elastic ratio of the liver for the intercostal muscle for each patient was calculated preoperatively, using the sonography device. The liver fibrosis stages were finally determined in the operative specimens from 41 patients. We examined the correlation between the elastic ratio and the histological fibrosis stage. RESULTS: The lower the elastic ratio, the more advanced was the liver fibrosis stage. There was a significant correlation between the elastic ratio and the histological fibrosis stage. The area under the receiver-operating characteristics curve for the diagnosis of significant liver fibrosis using this device was superior to those conventionally determined by blood parameters. CONCLUSIONS: Real-time elastography is a promising sonography-based noninvasive method for the preoperative assessment of liver fibrosis.

Usefulness of gemcitabine combined with 5-fluorouracil and cisplatin (GFP) in patients for unresectable biliary carcinoma.

BACKGROUND/AIMS: Advanced biliary carcinoma have poor prognosis and chemotherapy has been shown to have little impact. The aim of the present study is to clarify the effectiveness of GEM combined with CDDP and 5FU (GFP) therapy for unresectable biliary carcinoma. METHODOLOGY: Fourteen patients with biliary carcinoma (4 patients; gallbladder cancer, 10 patients; biliary tract) who had no prior chemotherapy were enrolled. A triple combination of agents was administered with a 4-week cycle GFP chemotherapy consisting of GEM at 1000 mg/m2 on days 1 and of 5-FU at 250 mg/m2 and CDDP at 3mg/m2 on days 1 to 5. RESULTS: No patient achieved CR, while five patients achieved PR as assessed by RECIST. The overall response rate from the intent-to-treat analysis was 21.4%. Stable disease was observed in 9 (64.3%) patients. Clinical benefit rate was observed in 14 (85.7%) patients. According to the tumor site, overall response rate was 20.0% in biliary tract carcinoma, on the other hand, 25.0% in gallbladder carcinoma. CONCLUSIONS: The significant antitumor activity of GFP chemotherapy has been seen in patients with advanced biliary carcinoma. However, further evaluation in large numbers of patients is needed to determine the difference in chemosensitivity according to the tumor site.

Indigo carmine dye-assisted lymphatic-sparing laparoscopic Palomo varicocelectomy in children.

UNLABELLED: The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques. MATERIALS AND METHODS: Five consecutive LSLVs were performed over a period of three years on children with a mean age of twelve years. The varicocele grade was three in one case and grade 2 in four cases, respectively. A left subdartos injection of 2 ml of Indigo carmine dye was done using a 25-gauge needle at ten minutes before an operation. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided. RESULTS: Lymphatic-sparing was accomplished in all cases. No peri-operative complication was noted. We spared one lymphatic channel in one patient (20%) and two channels in four patients (80%). There were no cases of hydrocele or residual varicocele. CONCLUSION: Dye-assisted LSLV is easily accomplished with an excellent surgical outcome and sparing one or two lymphatics appears to be sufficient to avoid secondary hydrocele.

Iliopsoas abscess in an infant.

Iliopsoas abscess (IPA) is uncommon in childhood and very rare in the neonate and infant. We present a case of IPA after an umbilical granuloma in an infant. A baby girl with a birth weight of 2,970 g was born at thirty-seven weeks and two days gestation by Caesarean Section. On the fourteenth day after birth, her umbilicus was wet and developed the granulomatous formation. At two months of age, she presented with right leg and groin swelling with mild bluish discoloration and without fever. She had poor movement of her right leg and showed apparent discomfort. Her umbilicus was dry and there was no granulomatous material. Ultrasonography and computed tomography demonstrated an iliopsoas abscess in the right position. Therefore, an extraperitoneal surgical drainage was performed, aspirating yellowish pus. Culture of the purulent material revealed Staphylococcus aureus. Systemic antibiotic therapy was continued for ten days. After three days of drainage, full-range motion of the right leg was gained, and then after eleven days, CT findings comfirmed the disappearance of the iliopsoas abscess. IPA is extremely rare and it is difficult to diagnose. However, it should be included in the differential diagnosis of an infant with poor leg movement and swelling of the groin to the femur.

Torsion of an accessory spleen with situs inversus in a child.

We present an unusual case of acute abdomen caused by torsion of an accessory spleen with situs inversus in a child. A three-year-old girl was admitted to our hospital with an 11-day history of right flank pain with fever. Her medical history revealed an operation of coarctation of the aorta with situs inversus at one month of age. Physical examination revealed a right flank mass and tenderness. A contrast-enhanced CT scan showed a normally enhanced small spleen in the right upper quadrant and a 7.0×6.0×3.5 cm, hypodense, marginal enhancing mass in the right midabdomen adjacent to the intestine. An emergency laparotomy was decided upon with a preoperative diagnosis as an acute abdomen. During surgery, a mass was found under the greater omentum and two accessory spleens of 1.5 cm in diameter were found surrounding the main spleen. Several loops of bowel were adherent to the mass. The loops of bowel were dissected away. A pediculated congested mass was observed as an accessory spleen emerging from the greater omentum. The mass was twisted on its vascular pedicle and strangulated. The necrotic mass was removed and the postoperative recovery was uneventful. Though torsion of an accessory spleen is extremely rare, it should be considered in the differential diagnosis of acute abdomen in childhood.

Successful preemptive surgical division of type 2-congenital extrahepatic portosystemic shunt in children.

PURPOSE: A congenital extrahepatic portosystemic shunt (CEPS) is a rare abnormality. The shunts are classified into 2 types. Of these, a type 2-shunt is a side-to-side one, which may be treated by a simple shunt division. The aim of this retrospective study was to clarify the effects of a surgical shunt division on 4 children with type 2-CEPS. PATIENTS: Between June 2002 and June 2008, 4 children with type 2-CEPS underwent a surgical shunt division. Various clinical factors of each patient, including shunt types, shut ratios evaluated by portal scintigraphy using (123)I-iodoamphetamine, serum levels of ammonia and total bile acids before and after surgery were evaluated. FINDINGS: Two children had a conventional open surgery and the other two had a laparoscopic surgery. The serum levels of ammonia as well as total bile acids of these children decreased significantly to the normal levels within a month after the surgical shunt divisions. All the children had a better clinical course. CONCLUSIONS: A shunt division, especially by laparoscopic surgery, is an effective therapy for type 2-CEPS. To the best of our knowledge by reviewing literatures, our cases are the youngest ones treated by laparoscopic shunt division.

Current concept of small-for-size grafts in living donor liver transplantation.

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called "small-for-size (SFS) graft syndrome." The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.

Efficacy of vessel sealing system for major Glisson bundles and major bile ducts.

BACKGROUND/PURPOSE: The efficacies of vessel sealing system (VSS) devices for major Glisson bundles and major bile ducts have not yet been determined. METHODS: Male pigs (n = 6) and a LigaSure V device and an Atlas 20 (Valleylab, Boulder, CO, USA) device were used in this study. After laparotomy, the common bile duct and the right and left first-degree Glisson bundles were sealed by the VSS. The lower and upper parts of the common bile ducts were also sealed. Macro-and microscopic examinations were performed for the analysis of specimens taken just after VSS application. In an analysis of bile duct specimens taken 1 week after the VSS application, both burst pressure tests and histological examinations were performed. RESULTS: (1) In the analysis of the specimens (Glisson bundles and bile ducts) obtained just after the VSS application, the macroscopic changes included permanent, flattened changes of the Glisson bundles and bile ducts, without showing any blood or bile leakage. Histological examination of the transverse sections of the Glisson bundle after VSS application revealed that not only the blood vessels but also the bile ducts were fused together. (2) In the analysis of the specimens (bile ducts) obtained 1 week after the VSS application, second-look laparotomy showed extrahepatic bile duct obstruction. The mean burst pressure of the sealed bile ducts was 74.4 +/- 20.1 mmHg. Histological examination revealed that the lumen of the bile duct was completely sealed and the duct was surrounded by dense connective tissues. CONCLUSIONS: The VSS is useful for the safe sealing of not only the major Glisson bundles but also the major bile ducts.