[Prophylactic portal vein stenting in a patient with local recurrence of cholangiocarcinoma without clinical symptoms of portal vein stenosis - a case report]

A 70-year-old man was diagnosed with local recurrence 1 and half years after pancreatoduodenectomy for extrahepatic cholangiocarcinoma. Progression of the recurrent tumor involved the portal vein, even though the patient had received chemotherapy (gemcitabine). Although no clinical symptoms caused by portal venous stenosis were found at the time, we performed percutaneous transhepatic portal vein stenting to avoid interrupting chemotherapy. Eighteen months after this procedure, the patency of the portal vein stent was well maintained, and the patient was treated with S-1 chemotherapy continuously without any symptoms related to portal venous stenosis reported. Prophylactic portal vein stenting without clinical symptoms of portal vein stenosis is a useful procedure, not only for palliative care but for improving the prognosis of patients with cholangiocarcinoma by continuous chemotherapy.

[Hepatic inferior vena cava resection and vascular prosthesis reconstruction for locally advanced intrahepatic cholangiocarcinoma - a case report]

A 61-year-old woman was referred to our hospital because of jaundice and general itching. Computed tomography (CT) scan demonstrated that the tumor was located in the caudate lobe of the liver with hilar invasion and involved the hepatic inferior vena cava (IVC) and the right renal artery and vein. The patient was diagnosed with locally advanced intrahepatic cholangiocarcinoma, for which she underwent right hemihepatectomy with right caudate lobectomy, portal vein resection, hepatic IVC resection, extrahepatic bile duct resection, and right nephrectomy. IVC was reconstructed using vascular prosthesis by expanded polytetrafluoroethylene (ePTFE)-ringed graft. The patient's postoperative course was uneventful. The patient was treated with gemcitabine for postoperative chemotherapy, and 3 years after the operation, she died due to recurrence resulting from peritoneal dissemination. Although the thrombosis-related vascular prosthesis obstruction had occurred 2 years after the operation, no clinical symptom were noted, such as lower leg edema or renal dysfunction, during the postoperative course. Hepatic IVC prosthesis reconstruction for locally advanced cancer with extensive IVC invasion can be a useful surgical procedure for improving the resection rate and maintaining quality of life (QOL) in such cases.

Tips and tricks of surgical technique for pancreatic cancer: portal vein resection and reconstruction (with videos)

Surgical resection is the only hope for cure in patients with pancreatic cancer. To improve the resectability and achieve better prognosis of this lethal disease, extended resection for pancreatic cancer has been applied. We have performed portal vein resection aggressively for pancreatic cancer with portal vein invasion. We also established a method of portal vein reconstruction using the left renal vein graft for tumors widely extended to the portal vein. Our data show similar survival between patients with portal vein obstruction and those without invasion. We also show that portal vein reconstruction using the left renal vein graft can be performed safely without severe liver damage. With video, we introduce our surgical technique for portal vein resection and reconstruction, especially focusing on the usage of the left renal vein graft, providing several tips for a safe and successful procedure.

Preoperative diagnosis and surgical management for solid pseudopapillary neoplasm of the pancreas

BACKGROUND

Preoperative diagnosis of solid pseudopapillary neoplasm of the pancreas (SPN) remains difficult and optimal surgical management for SPN has yet to be fully defined.

METHODS

Retrospective analysis was undertaken of all 10 patients (six women, four men) who underwent surgery for SPN between 2001 and 2013.

RESULTS

Mean age was 26 years (range, 16-33 years) for women, and 50 years (range, 35-76 years) for men. Although large SPN showed typical imaging findings, small SPN (≤ 3.0 cm) appears as almost entirely solid tumors. Endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) was performed in six patients with atypical findings of SPN for differentiation from other pancreatic neoplasms. Definitive preoperative cytological diagnosis was achieved in all patients who underwent EUS-FNA. All 10 patients underwent surgical exploration. One patient with portal vein invasion and multiple lung metastases underwent pancreaticoduodenectomy combined with portal vein resection and reconstruction, followed by two pulmonary resections. This patient remains alive as of 34 months after the initial operation.

CONCLUSIONS

Endoscopic ultrasound-guided fine-needle aspiration is useful for definitive preoperative diagnosis of SPN. As long-term survival after surgical resection can be achieved even in patients with locally advanced and metastatic SPN, aggressive surgical resection should be performed.

Usefulness of pure laparoscopic hepatectomy for hepatocellular carcinoma in a severely cirrhotic patient

The number of patients undergoing laparoscopic hepatectomy has rapidly increased in recent years, and indications for this procedure are gradually expanding. Pure laparoscopic hepatectomy is reportedly useful in cases with severe liver cirrhosis. A 55-year-old woman under observation for liver cirrhosis was found to have hepatocellular carcinoma in liver segment III and was referred to our hospital for surgery. The tumor was located in the edge of liver segment III, where percutaneous ablation therapy was unsuitable. Since her hepatic functional reserve was poor, pure laparoscopic partial hepatectomy was performed. The postoperative course was favorable, with no ascites retention, edema or weight gain. The greatest advantage of pure laparoscopic hepatectomy for hepatocellular carcinoma with concomitant liver cirrhosis is that postoperative ascites retention is minimal, meaning that there is little risk of water-electrolyte imbalance associated with ascites retention or hypoproteinemia. This is believed to be because the abdominal incision is small and mobilization of the liver is minimized, reducing the destruction of the routes of collateral lymph flow and blood flow generated in patients with liver cirrhosis. Pure laparoscopic hepatectomy may be a treatment choice for patients with hepatocellular carcinoma and concomitant severe liver cirrhosis.

Recent advances and problems in the management of pancreaticobiliary maljunction: feedback from the guidelines committee

Clinical practice guidelines on how to deal with pancreaticobiliary maljunction (PBM) were made in Japan in 2012, representing a world first. Using a narrow definition, congenital biliary dilatation involves only Todani type I (except type Ib) and type IV-A, both of which are accompanied by PBM in almost all cases. Prospective ultrasonographic study revealed that the maximum diameter of the common bile duct increased with age. Pathophysiological conditions due to pancreatobiliary reflux occur in patients with high confluence of the pancreaticobiliary ducts, a common channel ≥ 6 mm long and occlusion of communication during contraction of the sphincter of Oddi. Since PBM can be diagnosed by magnetic resonance cholangiopancreatography, multi-planar reconstruction multi-detector row computed tomography and endoscopic ultrasonography, the current diagnostic criteria should be revised to take these diagnostic imaging modalities into consideration. According to a nationwide survey, biliary cancer occurred in 21.6% of adult patients with PBM with biliary dilatation and 42.2% of patients with PBM without biliary dilatation. In biliary cancer associated with PBM without biliary dilatation, 88.1% were gallbladder cancer. Treatment for PBM with biliary dilatation is prophylactic flow-diversion surgery, but further investigations and surveillance studies are needed to clarify the appropriate surgical strategy for PBM without biliary dilatation.

A randomized phase II trial of adjuvant chemotherapy with S-1 versus S-1 and gemcitabine (GS) versus gemcitabine alone (GEM) in patients with resected pancreatic cancer (CAP-002 study)

4056

Background: Although the adjuvant therapy using GEM is now the standard therapy for patients with resected pancreatic cancer (PC), the prognosis still remains poor. Resent study demonstrated the non-inferiority of S-1 and superiority of GS to GEM with respect to progression free survival in patients with unresectable pancreatic cancer. Methods: Patients with invasive ductal PC who underwent radical surgery were enrolled. After stratification for R0/1, stage and institution, patients were randomized to receive GEM (GEM 1g/ m2, iv, d1, 8, and 15, q4w X12), S-1 (80/100/120mg/day based on BSA, po, d1-14, q3w X 16) or GS (S-1 60/80/100mg/day based on BSA po, d1-14 plus GEM 1g/ m2, iv, d8, 15, q3w X 16) within 8weeks after operation. Eligibility included histological residual tumor (R) 0 or 1, and no previous chemo- or/and radiation therapy. Primary endpoint was 2y disease free survival (DFS) rate and secondary endpoints included overall survival (OS), and safety. Results: Between January 2007 and October 2010, 96 patients were randomized into the three arms of the trial (32 pts to each group). Patients’ characteristics were well balanced (GEM/S-1/GS) with regard to age (66/67/66y), tumor location (head 66/69/75%), tumor status (T3+4 88/78/91%), and nodal status (positive 75/69/75%). Until November 2012, 74 events (77%) have occurred for DFS. Two year DFS rate was 24.2%, 28.1% and 34.4% in GEM, S-1 and GS, respectively and there was no significant difference between groups. The median OS was 21m in GEM, 26m in S-1 and 27.9m in GS (Log rank test: N.S.). Grade 3/4 toxicities in GEM/S-1/GS were hematological 63/10/74% and non-hematological 17/10/23%, respectively. No treatment related death was observed during the study. Conclusions: S-1 and GS provided similar efficacy to GEM as the adjuvant chemotherapy for resected PC. According to the results, S-1 and GS is the adequate combination for phase III trial to examine the efficacy of adjuvant chemotherapy for PC. Clinical trial information: UMIN000002000.

Surgical resection after downsizing chemotherapy for initially unresectable locally advanced biliary tract cancer: a retrospective single-center study

BACKGROUND

Surgical resection is the only method for curative treatment of biliary tract cancer (BTC). Recently, an improved efficacy has been revealed in patients with initially unresectable locally advanced BTC to improve the prognosis by the advent of useful cancer chemotherapy. The aim of this study was to evaluate the effect of downsizing chemotherapy in patients with initially unresectable locally advanced BTC.

METHODS

Initially unresectable locally advanced cases were defined as those in which therapeutic resection could not be achieved even by proactive surgical resection. Gemcitabine was administered intravenously once a week for 3 weeks followed by 1 week's respite. Patients whose disease responded to chemotherapy were reevaluated to determine whether their tumor was resectable.

RESULTS

Chemotherapy with gemcitabine was provided to 22 patients with initially unresectable locally advanced BTC. Tumor was significantly downsized in nine patients, and surgical resection was performed in 8 (36.4%) of 22 patients. Surgical resection resulted in R0 resection in four patients and R1 resection in four patients. Patients who underwent surgical resection had a significantly longer survival compared with those unable to undergo surgery.

CONCLUSIONS

Preoperative chemotherapy enables the downsizing of initially unresectable locally advanced BTC, with radical resection made possible in a certain proportion of patients. Downsizing chemotherapy should be proactively carried out as a multidisciplinary treatment strategy for patients with initially unresectable locally advanced BTC with the aim of expanding the surgical indication.

[A case of pancreaticoduodenectomy for duodenal carcinoma with a replaced common hepatic artery running through the pancreatic parenchyma]

To perform safe and radical pancreaticoduodenectomy, adequate knowledge of the branching and running course of the common hepatic artery is necessary. Formation of a common trunk by the common hepatic artery and superior mesenteric artery, called the hepatomesenteric trunk, is very rare. When it occurs, the common hepatic artery arising from the hepatomesenteric trunk usually runs behind the pancreas head. In the present case, however, it ran through the pancreatic parenchyma. Therefore, pancreaticoduodenectomy for duodenal carcinoma was performed with preservation of the intrapancreatic common hepatic artery. When pancreaticoduodenectomy is performed in patients with a replaced common hepatic artery running through the pancreatic parenchyma, it is necessary to preoperatively determine whether to preserve or resect the common hepatic artery in the pancreas with consideration of the curability. If resected, whether to reconstruct it must also be determined. If reconstructed, the reconstruction method must be determined, and if not, it is important to perform preoperative coiling of the common hepatic artery and intraoperative measurement of the hepatic blood flow with a Doppler flow meter.

Usefulness of preoperative partial splenic embolization in hepatocellular carcinoma and hypersplenic thrombocytopenia

BACKGROUND/AIMS

Patients with both hepatocellular carcinoma and hypersplenic thrombocytopenia are occasionally seen and this condition can severely complicate liver resection. This study evaluated the usefulness of preoperative partial splenic embolization (PSE) as an alternative to splenectomy (SP).

METHODOLOGY

Twenty-eight patients with hypersplenic thrombocytopenia underwent hepatectomy for hepatocellular carcinoma. Five patients underwent preoperative PSE and 23 patients underwent concomitant splenectomy. The blood cell counts, laboratory chemistry data, and operative morbidity, prognosis were all examined.

RESULTS

There were no severe PSE-related complications such as splenic abscess seen after PSE. The platelet counts in the PSE group significantly increased in comparison to those in the SP group before the operation. The frequency of blood transfusion and postoperative complications in the PSE group was significantly less than that in the SP group. The duration of surgery, blood loss, and performance of PSE were significant factors to predict postoperative complications. The overall survival after liver resection was not significantly different between patients in the PSE and SP group.

CONCLUSIONS

Preoperative PSE could be safely performed without severe adverse effects prior to liver resection and it was thus considered to be useful for increasing the number of platelets and reducing postoperative complications.

[A successful treatment of conversion chemotherapy by mFOLFOX6 plus cetuximab for initially unresectable synchronous colorectal liver metastases]

A 63-year-old woman with a synchronous huge colorectal liver metastasis was referred to our institution.The lesion was technically diagnosed unresectable because the estimated future remnant liver volume was insufficient due to the invasion of the three hepatic veins and hepatic hilum.She underwent 7 courses of mFOLFOX6 and 14 administrations of cetuximab as conversion chemotherapy.Periodic abdominal CT scans revealed the tumor becoming PR, and she was free of cancer invasion to the left hepatic vein.After the remainder of chemotherapy lasting 4 weeks, right trisectionectomy and combined partial resection of the inferior vena cava and primary closure was performed.The postoperative course was uneventful and the patient was discharged at 20 days after the operation.She underwent chemotherapy postoperatively, and then underwent laparoscopic sigmoidectomy.A conversion chemotherapy using cetuximab may contribute to ward rapidly reducing tumor size and improving the resectability of initially unresectable huge colorectal liver metastases, thus leading to prolonged survival.

Similarities and differences between intraductal papillary tumors of the bile duct with and without macroscopically visible mucin secretion

Intraductal papillary neoplasms of the bile duct (IPNB) have been recently proposed as the biliary counterpart of intraductal papillary mucinous neoplasms of the pancreas (IPMN-P). However, in contrast to IPMN-P, IPNB include a considerable number of the tumors without macroscopically visible mucin secretion. Here we report the similarities and differences between IPNB with and without macroscopically visible mucin secretion (IPNB-M and IPNB-NM). Surgically resected 27 consecutive cases with IPNB were divided into IPNB-M (n=10) and IPNB-NM (n=17), and their clinicopathologic features were examined. Clinically, both tumors were similar. Pathologically, the most frequent histopathologic types were pancreatobiliary in IPNB-NM and intestinal in IPNB-M. Various degrees of cytoarchitectural atypia within the same tumor were exhibited in 8 IPNB-M, but only 3 in IPNB-NM. Although the tumor size was similar, 9 IPNB-NM were invasive carcinoma, whereas all but 1 IPNB-M with carcinoma were in situ or minimally invasive. Immunohistochemically, positive MUC2 expression was significantly more frequent in IPNB-M than in IPNB-NM, whereas MUC1 tended to be more frequently expressed in IPNB-NM compared with IPNB-M. Among IPNB-NM with positive MUC1 expression, 3 had negative MUC2 and MUC5AC expressions. These tumors showed a tubulopapillary growth with uniform degree of cytoarchitectural atypia. All IPNB-M were negative for p53, and the frequency of positive p53 protein in IPNB-NM was at the middle level of that in IPNB-M and nonpapillary cholangiocarcinoma. In conclusion, IPNB-M showed striking similarities to IPMN-P, but IPNB-NM contained heterogeneous disease groups.

[Two-stage hepatectomy combined with converting chemotherapy achieved a successful treatment for initially unresectable multiple bilobar colorectal liver metastases]

A 60-year-old man having metachronous multiple bilobar colorectal liver metastases was referred to our institution. The lesions were diagnosed unresectable due to a lack of the estimated future remnant liver volume. He underwent 13 courses of mFOLFOX6 + bevacizumab as down-staging chemotherapy. The periodic abdominal CT scans revealed metastatic lesions to become PR. We had decided to perform two-stage hepatectomy to preserve a hepatic functional reserve. After the rest of chemotherapy for 4 weeks, four tumors were resected and right branch of the portal vein embolization was performed at the first operation. Right hemihepatectomy was performed 5 weeks after the first operation to achieve curative resection. Postoperative course was uneventful and the patient was discharged at 17 days after the operation. He has no signs of tumor recurrence during the follow-up. The combination of two-stage hepatectomy and neoadjuvant systemic chemotherapy may contribute to improve prognoses of initially unresectable multiple bilobar colorectal liver metastases, leading to prolonged survival.

[A case of cholangiocarcinoma with hepatomesenteric trunk and intestinal malrotation treated with pancreaticoduodenectomy]

The patient was a 61-year-old man. He was underwent pancreaticoduodenectomy for common bile duct cancer. The preoperative dynamic CT revealed that hepatic artery was branched from the superior mesenteric artery, run through pancreatic surface caudal to cranial and flowed into liver. And this vessel had several branches into pancreas. In operation, to ensure blood flow to the liver, hepatic artery was detached from pancreas by cutting off branches into pancreas. In addition, intestinal malrotation was also confirmed (Treitz ligament was not formed and small intestine was present in the right side of abdominal space, while colon was present in the other side). Performing a pancreatoduodenectomy for malignant tumors, it is very important to recognize the variation of hepatic artery, because of the necessity for the consideration of blood flow to the liver. In this case, we indicated a preservation of hepatic artery with adequate lymph node dissection.

[A resected case of non-invasive type of intraductal papillary mucinous carcinoma penetrating to the duodenum]

A 74-year-old man was admitted to a nearby clinic complaining of high fever. Abdominal CT showed a 10 mm diameter cystic mass in the head of pancreas and dilation of the pancreatic duct. Endoscopy revealed a fistula filled with mucin in the posterior wall of the duodenum. The patient was referred to our institution for a surgical resection. Endoscopic ultrasonography revealed dilation of the pancreatic duct and also mural nodules in the pancreatic duct, ERP demonstrated a fistula from the pancreatic duct to the duodenum. Biopsied specimen from the papillary nodule in the pancreatic duct showed adenoma. We performed pancreaticoduodenectomy for main-duct IPMN penetrating to the duodenum. Pathological findings showed a non-invasive type of IPMC. Furthermore, a cancer invasion to the duodenum was not detected. These findings suggest that the increased pressure within the pancreatic duct caused a fistula to the duodenum.

[Percutaneous transhepatic portal vein stenting for portal hypertension caused by local recurrence of intrahepatic cholangiocarcinoma]

A 62-year-old woman underwent an extended left hepatectomy with a combined resection of portal vein and extrahepatic bile duct for intrahepatic cholangiocarcinoma (ICC). After 7 years, she presented with repeated tarry black stool and severe anemia. The source of bleeding was not identified on upper and lower gastrointestinal endoscopy. Computed tomography (CT) revealed a small hypodence lesion at portal hepatis, by which portal vein (PV) stenosis was induced in the absence of sufficient development of portal venous collateral. Positron emission tomography revealed an accumulation of fluorodeoxy glucose around PV obstruction. Based on these findings, we diagnosed that the local recurrence of ICC, which resulted in mesenteric hypertension and small bowel varices. Therefore, portal stent placement was carried out under percutaneous transhepatic portgraphy to maintain portal blood flow. An uncovered expandable metallic stent was inserted into the stenotic region. Portgraphy after the stent replacement showed a relief of the PV stenosis and disappearance of the collateral pathways. After this procedure, the patient had no additional episode of gastrointestinal hemorrhage. Our experience suggests that stent placement for postoperative PV stenosis is recommended as a useful treatment for gastrointestinal bleeding caused by portal hypertension that is less invasive.

[Transcatheter arterial chemoembolization prolonged survival in a patient with advanced hepatocellular carcinoma accompanied by tumor thrombus of the portal vein trunk]

A 50-year-old man having an advanced hepatocellular carcinoma (HCC) was admitted to our institution. An abdominal computed tomogram showed infiltrative mass in the right liver with tumor thrombus invading into the main trunk and contralateral branch of the portal vein. Repetitive transcatheter arterial chemoembolization reduced a tumor size and shrunken portal vein tumor thrombus. The tumor marker levels such as AFP and PIVKA-II decreased. During follow-up, he was diagnosed as having an impending rupture of HCC with acute abdominal pain. He was successfully treated with interventional technique. He died of liver failure 66 months after the first treatment. Although he had a highly advanced HCC with tumor thrombus of the portal vein, repetitive transcatheter arterial chemoembolization therapy may prolong survival.

One hundred seven consecutive surgical resections for hilar cholangiocarcinoma of Bismuth types II, III, IV between 2001 and 2008

Many authors at high-volume centers all over the world have reported improved outcomes of hilar cholangiocarcinoma by several aggressive surgical approaches such as extended hepatic resection, combined vascular resection, and hepatopancreaticoduodenectomy in recent years. There has been great progress in the surgical treatment of hilar cholangiocarcinoma with these previous efforts by aggressive hepatobiliary surgeons. In particular, surgical techniques, diagnostic modalities, and perioperative management have been remarkably improved as compared with before. Herein we report the surgical outcome for both hilar cholangiocarcinoma of Bismuth types II, III, and IV and intrahepatic cholangiocarcinoma involving the hepatic duct confluence during the recent 8-year period between 2001 and 2008 at our institution, the Department of General Surgery at Chiba University. From our recent experienced results, it can be concluded that the surgical strategy for hilar cholangiocarcinoma has been improved remarkably, and major surgical hepatectomy can be done with relative safety, and these aggressive surgical approaches, including combined vascular resection, may be warranted for the surgical treatment of hilar cholangiocarcinoma. However, the adoption of new innovative therapeutic approaches might be required for further improvement of surgical outcome of hilar cholangiocarcinoma.

Surgical strategy for mucin-producing bile duct tumor

Tumors with copious mucin production within the intra- or extrahepatic bile ducts have been reported as mucin-producing bile duct tumors (MPBTs). Because mucin produced by these tumors causes recurrent cholangitis and obstructive jaundice, surgical resection should be indicated even if these tumors are regarded as benign. In order to choose the appropriate surgical procedure, exact preoperative assessment of tumor location and cancer extension is important, especially evaluation of the extent of superficial spreading through cholangioscopic observation and biopsy. In principle, MPBTs should be resected in a manner similar to that employed for other types of bile duct carcinomas. That is, major hepatectomy with or without extrahepatic bile duct resection or pancreaticoduodenectomy should be chosen as the surgical procedure, and intraoperative frozen section at the stumps of the bile duct is essential. On the other hand, when precise diagnosis is completed preoperatively and the lesion is diagnosed as adenoma or carcinoma with invasion confined to the ductal wall and limited superficial spreading, limited resections preserving organ functions as much as possible can be considered as a choice among surgical procedures. All ten patients with MPBT resected at our institution according to these strategies are still alive without tumor recurrence, with a median survival of 48.0 months.

Significance of repeated resection for recurrent intrahepatic cholangiocarcinoma

BACKGROUND/AIMS

Management of patients with recurrent intrahepatic cholangiocarcinoma (ICC) following surgical resection is difficult, and surgical resection is rarely indicated. We retrospectively reviewed patients with recurrent intrahepatic cholangiocarcinoma.

METHODOLOGY

Between April 1998 and March 2007, 57 consecutive patients with ICC underwent surgical resection. Mode of recurrence and treatment of recurrent tumors, especially surgical resection for these tumors, in patients with cancer recurrence were evaluated.

RESULTS

37 (65%) patients experienced tumor recurrence. Out of these patients, 24 underwent some type of cancer-directed therapy, including 9 patients (24%) for whom surgical resection was attempted: the latter included 4 hepatic resections, 2 pulmonary resections, 2 tumor resections, and 1 gastric resection. For 6 patients with recurrent tumor in the liver or the lung, microscopic complete resection was achieved, while incomplete resection was resulted in the remaining 3 patients. No postoperative mortality was encountered. Among patients with complete resection, 3 are alive without disease 32, 39 and 77 months after the second operation, one has lived with disease for 13 months, and 2 died of disease after 22 and 26 months. No significant difference in overall survival was observed between patients undergoing primary and second surgical resections, calculated from the primary and the second operations, respectively.

CONCLUSIONS

Repeated surgical resection for recurrent ICC can be performed with acceptable morbidity, and affords selected patients a chance for long-term survival.

Usefulness of intraoperative fluorescence imaging to evaluate local anatomy in hepatobiliary surgery

BACKGROUND/PURPOSE

One of the major complications encountered in hepatobiliary surgery is the incidence of bile duct and blood vessel injuries. It is sometimes difficult during surgery to evaluate the local anatomy corresponding to hepatic arteries and bile ducts. We investigated the potential utility of an infrared camera system as a tool for evaluating local anatomy during hepatobiliary surgery.

METHODS

An infrared camera system was used to detect indocyanine green fluorescence in vitro. We also employed this system for the intraoperative fluorescence imaging of the arteries and biliary system in a pig. Further, we evaluated blood flow in the hepatic artery, portal vein, and liver parenchyma during a human liver transplant and we investigated local anatomy in patients undergoing cholecystectomy.

RESULTS

Fluorescence confirmed that indocyanine green was distributed in serum and bile. In the pig study, we confirmed the fluorescence of the biliary system for more than 1 h. In the liver transplant recipient, blood flow in the hepatic artery and portal vein was confirmed around the anastomosis. In most of the patients undergoing cholecystectomy, fluorescence was observed in the gallbladder, cystic and common bile ducts, and hepatic and cystic arteries.

CONCLUSIONS

Intraoperative fluorescence imaging in hepatobiliary surgery facilitates better understanding of the anatomy of arteries, the portal vein, and bile ducts.

[Aggressive surgical treatment prolonged survival of a patient with synchronous hepatocellular carcinoma with tumor thrombus in the inferior vena cava and sigmoid colon cancer]

A 71-year-old man was admitted to our institution having a HCC with tumor thrombus extending to the inferior vena cava. He simultaneously had a sigmoid colon cancer. S8 segmentectomy combined with a removal of tumor thrombus in the IVC and sigmoidectomy was performed. He had an uneventful postoperative course. He had a recurrence to the lung 46 months after the surgery, and underwent a pulmonary partial resection. Hepatic recurrence was found in 59 months after the initial surgery. Transcatheter arterial chemoembolization was performed for the treatment. The patient died of esophageal variceal rupture 78 months after the surgery. Although this case was a highly advanced hepatocellular carcinoma with tumor thrombus in the inferior vena cava and synchronous sigmoid colon cancer, a surgical treatment and multidisciplinary therapy may contribute to a long-term survival.

Infectious tolerance develops after intrathymic alloantigen-induced acceptance of rat heart allografts can be adoptively transferred

BACKGROUND

We have shown that intrathymic (IT) injection of alloantigen with antirat lymphocyte serum (ALS) treatment can induce donor-specific allograft acceptance. The purpose of this study was to investigate whether T-regulatory (T-reg) cells play a role in the maintenance of donor-specific heart graft tolerance that develops after IT injection of Lewis (LEW, RT1(l)) alloantigen into a Dark Agouti (DA, RT1(a)).

METHODS

Naïve DA rats were injected IT with 2.5 x10(7) LEW donor splenocytes and injected intraperitoneally with 1 mL ALS. Twenty-one days after pretreatment, a LEW or Brown Norway (BN, RT1(n)) heart was transplanted into a treated DA recipient. Splenocytes (1 x 10(8) or 5 x 10(7)) from a LEW heart-tolerant long-term survivor (LTS; >60 days) DA recipient were harvested and adoptively transferred (AT) into an irradiated (450 rad) naïve DA rat 24 hours before transplanting a LEW heart.

RESULTS

All LEW heart allografts were rejected by untreated DA rats in a mean survival time (MST) of 7.4 +/- 1.7 days (n=7). In contrast, 66.7% of LEW heart grafts into IT+ALS-pretreated DA recipients were accepted indefinitely (n=24). When either 1 x 10(8) (n=5) or 5 x 10(7) (n=5) splenocytes from a LEW heart graft-tolerant LTS (>60 days) DA recipient were AT into a new naïve DA rat, all new LEW heart grafts were accepted indefinitely.

CONCLUSIONS

The donor-specific tolerance that develops after IT+ALS-induced LEW heart acceptance by DA recipients can be transferred adoptively to new naïve DA recipients, thus indicating that it is infectious tolerance.

The persistence of regulatory cells developing after rat spontaneous liver acceptance

BACKGROUND

We have previously reported that the spontaneous acceptance of Lewis (LEW, RT1(l)) to Dark Agouti (DA, RT1(a)) rat orthotopic liver transplant (OLT) is eliminated by donor gamma-irradiation. The acceptance of the irradiated LEW liver is also reestablished in a naïve rat after the adoptive transfer of T regulatory (T-reg) cells from a LEW to a DA liver-tolerant long-term (>60 days) survivor (LTS) into a naïve DA rat. However, little is known about the growth conditions required to maintain T-reg function. In this study, we examined the need for continued donor-specific alloantigen stimulation for the maintenance and function of T-reg cells.

METHODS

Splenocytes (SCs; 1.5 x 10(8) cells) from a LEW liver allograft-tolerant LTS DA recipient were adoptively transferred fresh or after in vitro stimulation into another naive DA rat on day 1, 4, or 7 before an irradiated (1000R) LEW liver transplant. For in vitro alloantigen stimulation, SCs from LEW to DA LTS were co-cultured with mitomycin-C (MMC)-treated naïve LEW (donor alloantigen-specific) or Brown Norway (BN) (RT1(n); third party) SCs for 72 hours. Graft rejection, as defined by death of the recipient, was confirmed histologically.

RESULTS

All LEW liver grafts were accepted spontaneously by DA recipients for more than 60 days (n=32), while all irradiated LEW livers were acutely rejected (n=9; mean survival time [MST]=12.8 +/- 4.0 days). When LTS DA SCs were adoptively transferred into a naive DA rat 1 day before OLT, all irradiated LEW grafts were accepted greater than 60 days (n=9). However, when fresh LTS DA SCs were transferred to a new naïve DA rat on 4 or 7 days before OLT, all irradiated LEW liver grafts were acutely rejected (MST=10.2 +/- 0.5 days [n=4] and MST=13.5 +/- 5.0 days [n=4], respectively). When LTS DA SCs were stimulated in vitro before adoptive transfer, irradiated LEW liver grafts after 4 days (n=5) were then accepted. In vitro culture of LTS DA SCs with MMC-treated BN SCs (third-party) for 72 hours before adoptive transfer resulted in 3 of 5 irradiated LEW livers at day 4 being accepted (n=5).

CONCLUSIONS

The maintenance of T-reg function requires continuous LEW donor-specific alloantigen stimulation.

Increased expression of toll-like receptor 4 enhances endotoxin-induced hepatic failure in partially hepatectomized mice

BACKGROUND/AIMS

Liver failure associated with infections after hepatectomy remains a cause of mortality. It has recently been reported that toll-like receptor 4 (TLR4) is involved in recognizing lipopolysaccharides (LPS). The aim of this study was to investigate the role of TLR4 in endotoxin-induced liver injury after hepatectomy.

METHODS

C3H/HeN and C3H/HeJ mice underwent 70% hepatectomy or sham surgery, and LPS was administered 48 h after surgery. Expression of TLR4 mRNA, nuclear factor-kappaB (NF-kappaB) activation, tumor necrosis factor-alpha (TNF-alpha) and serum ALT levels, histological findings, and myeloperoxidase content were examined. Survival after LPS administration was also determined.

RESULTS

Hepatic expression of TLR4 was significantly increased 6-72 h after hepatectomy. In mice with endotoxemia after hepatectomy, hepatic NF-kappaB activation was greatly increased. Hepatic mRNA and serum levels of TNF-alpha, and ALT levels were significantly elevated compared with sham operated controls. Focal necrosis with neutrophil infiltration was apparent, which is consistent with increased myeloperoxidase contents in endotoxemia after hepatectomy in C3H/HeN mice. These were completely absent in C3H/HeJ mice. Survival of C3H/HeN mice with endotoxemia after hepatectomy was significantly lower than that of C3H/HeJ mice.

CONCLUSIONS

Upregulated TLR4 expression and function after hepatectomy plays a pivotal role in endotoxin-induced liver injury after hepatectomy.

Double cancer of gallbladder and bile duct associated with anomalous junction of the pancreaticobiliary ductal system

We report a case of double cancer of the gallbladder and the common bile duct associated with anomalous junction of the pancreaticobiliary ductal system, and review the literature of similar case reports. A 66-year-old woman was admitted to an associated hospital complaining of upper abdominal pain, and was diagnosed as having pancreatitis. Abdominal imaging revealed an irregularly protruding mass at the body of the gallbladder and an intraluminal protrusion at the lower third of the common bile duct. Endoscopic retrograde cholangiopancreatography also revealed anomalous junction of the pancreaticobiliary ductal system with congenital biliary dilatation of 14 mm in the largest diameter. She underwent surgical resection of the gallbladder, the extrahepatic bile duct and the gallbladder bed of the liver with a dissection of the regional lymph nodes for double cancer of the gallbladder and the bile duct associated with anomalous junction of the pancreaticobiliary ductal system. She is still alive 33 months after surgery without any signs of recurrence. There were 12 patients (including our case) reported in the literature who had double cancer of the gallbladder and the extrahepatic bile duct associated with anomalous junction of the pancreaticobiliary ductal system. Only 33% of these 12 patients had jaundice. Tumors of the 12 patients were commonly early-stage cancer both in the gallbladder (36%) and in the extrahepatic bile duct (73%). Therefore, we concluded that precise preoperative imaging of the total biliary tract should be required in order to detect early-stage cancer in patients with anomalous junction of the pancreaticobiliary ductal system before planning surgical procedures, and consideration should be given to the possibility of multiple occurrences of biliary tract cancers.