Laparoscopic Anatomical Liver Resection of Segment VIII by Using ICG Fluorescence Positive Staining Under the Guidance of Laparoscopic Ultrasonography

BACKGROUND

Anatomical segmentectomy is a surgical procedure that completely removes a territory (or territories) of the third-order portal venous branches of a Couinaud segment (Wakabayashi et al. in J Hepatobil Pancreat Sci 29(1):82-98, 2022. https://doi.org/10.1002/jhbp.899 ). Laparoscopic segmentectomy of S8 is considered technically challenging because of the Precise dissection of the Glissonean pedicle of S8, and exposure of the middle and right hepatic veins are required (Ome et al. in J Am Coll Surg 230(3):e13-e20, 2020; Wakabayashi et al. in Ann Surg 261(4):619-29, 2015. https://doi.org/10.1097/sla.0000000000001184 ; Monden et al. in J Hepatobil Pancreat Sci 29(1):66-81, 2022. https://doi.org/10.1002/jhbp.898 ). This report describes a new approach, which can reduce unwanted damage to normal tissues and complications.

METHODS

A 53-year-old man who has suffered from hepatitis B for 10 years was admitted for the treatment of two nodular tumors located in segment VIII. The surgical procedure began with the percutaneous injection of 5 mL, 0.025 mg/mL of ICG into the S8 portal branch by using an 18G PTCD needle under the guidance of laparoscopic ultrasound (Xu et al. in Surg Endosc 34(10):4683-4691, 2020. https://doi.org/10.1007/s00464-020-07691-5 ; Wang et al. in Ann Surg 274(1):97-106, 2021. https://doi.org/10.1097/sla.0000000000004718 ; Aoki et al. in J Am Coll Surg 230(3):e7-e12, 2020. https://doi.org/10.1016/j.jamcollsurg.2019.11.004 ), followed by liver transection on the cranial side of the liver, which used the ICG fluorescence images for exposing the roots of the middle and right hepatic veins and dissecting and ligating S8 portal pedicle. The excision specimen was sent for histopathological diagnosis.

RESULTS

It took 200 min for the operation and 60 min for the total Pringle maneuver. The estimate of blood loss was 110 mL. The final histopathologic results of the two nodules were hepatocellular carcinoma (HCC). The patient was discharged on postoperative Day 6 with no complications.

CONCLUSIONS

Laparoscopic anatomical liver resection of S8 has been demonstrated to be feasible. Under the guidance of laparoscopic ultrasonography, ICG positive staining was proven to be optimal for Anatomical segmentectomy.

Efficacy and safety of sequential therapy with sorafenib and regorafenib for advanced hepatocellular carcinoma: a two-center study in China

BACKGROUND

Regorafenib is a standard 2nd-line treatment for patients with advanced hepatocellular carcinoma (HCC), but the efficacy and safety of sequential therapy with sorafenib and regorafenib among advanced HCC patients in China is not clear.

METHODS

This was a retrospective, two-center, cohort study of advanced HCC patients who received sequential therapy of sorafenib and regorafenib from October 2018 to April 2020 at 2 Chinese institutions. The patients were converted directly to regorafenib after failing to respond to sorafenib monotherapy. The patients underwent evaluations every 4-6 weeks to determine the efficacy and safety of the treatment according to physiological, laboratory, and radiological results. A radiological evaluation using computed tomography or magnetic resonance imaging scans was conducted. The outcomes included overall survival (OS) and progression-free survival (PFS).

RESULTS

A total of 43 patients received regorafenib as a 2nd-line treatment after sorafenib progression. Of these patients, 26 (60.5%) and 17 (39.5%) were diagnosed with Barcelona Clinic Liver Cancer (BCLC) stages B and C, respectively. The median PFS was 11.0 [95% confidence interval (CI): 5.8-16.2] months, and the median OS was 17.0 (95% CI: 12.8-21.2) months. Conversely, the most common toxicities were hand-foot skin reaction (48.8%), diarrhea (32.6%), and hypertension (14%). The most common grade 3-4 toxicities were hypoalbuminemia (4.7%), anemia (4.7%), and thrombocytopenia (4.7%). Alpha-fetoprotein (AFP) ≥400, alanine transaminase (ALT) ≥60 IU/L, and aspartate aminotransferase (AST) ≥60 IU/L before 2nd-line treatment were associated with PFS in the univariable analyses. The Cox proportional-hazards regression analysis showed that AFP [hazard ratio (HR) =0.225; 95% CI: 0.073-0.688; P=0.009], ALT (HR =0.195; 95% CI: 0.051-0.741; P=0.016), AST (HR =0.209; 95% CI: 0.063-0.697; P=0.011), and presence of extrahepatic metastasis (HR =0.074; 95% CI: 0.009-0.608; P=0.015) before 2nd-line treatment were independently associated with PFS.

CONCLUSIONS

The sequential therapy of sorafenib and regorafenib is well-tolerated and effective in advanced HCC patients after sorafenib progression based on our two-center real-world data. Patients with good liver function reserve and a high level of AFP before 2nd-line treatment may benefit from sequential treatment. These results still need further validation.

Hemostasis in Danio rerio: is the zebrafish a useful model for platelet research?

New scientific models have been established in the past few years to identify novel factors of hemostasis and thrombosis and to analyze their function in greater detail. One fairly new animal model is the zebrafish, Danio rerio, which shares most of the central factors of platelet adhesion, activation, aggregation and release reaction with humans. Examples include GPIIb-IIIa, many other integrins, coagulation factors, inflammatory and cytokine-like proteins as well as arachidonic acid metabolism enzymes. Yet the zebrafish genome has undergone a teleost-specific genome duplication, causing the existence of duplicated paralogues in some instances, and a few genes have not been identified in the zebrafish genome. Taken together the high fecundity of the zebrafish, the possibility to observe transparent developing embryos in real time, the availability of a large number of mutants and transgenics as well as the possibility to knock down gene function by microinjection of morpholino antisense oligonucleotides and the similarity of the hemostatic system are important assets of the zebrafish, promising that it will be an attractive model to study thrombocyte function, thrombosis and hemostasis. This review provides an overview of the central factors of thrombocyte function identified so far in the zebrafish genome and a compilation of methods and tools available for the study of thrombocyte development and function in zebrafish.

Sequence analysis of zebrafish chondromodulin-1 and expression profile in the notochord and chondrogenic regions during cartilage morphogenesis

Chondromodulin-I (ChM-I) is suggested in higher vertebrate systems to function as a key regulatory protein for cartilage development. To further understand the process of chondrogenesis and the function of ChM-I, we have cloned the zebrafish cDNA for chondromodulin-1 (chm1) and have mapped the chm1 gene locus. The expression profile of chm1 was determined during zebrafish embryonic development and compared to that of type II collagen (col2a1). Maternal chm1 transcripts were detected before midblastula transition and zygotic expression of chm1 was first observed in the notochord at the 10-somite stage. At later developmental stages, chm1 expression was detected in areas surrounding the otic vesicles, in the developing craniofacial cartilage elements, and in the chondrogenic region of the pectoral fins.

Collagen content of alveolar wall tissue in emphysematous and non-emphysematous lungs

BACKGROUND

Emphysema is currently defined as "a condition of the lung characterised by abnormal, permanent enlargement of the airspaces distal to the terminal bronchiole, accompanied by destruction of their walls, and without obvious fibrosis." The functional and morphological changes that occur in emphysema have largely been attributed to changes in alveolar elastin rather than in collagen. A study was performed to determine whether the amount of collagen in the alveolar wall changes with age in the lungs of non-smokers and of smokers with different types of macroscopically defined emphysema in relation to a microscopic measurement of lung structure.

METHODS

Total alveolar wall collagen was measured (as hydroxyproline) in known volumes of distended lung tissue (by reverse phase high pressure liquid chromatography) in the lungs of non-smokers (n = 23) and in regions sampled away from emphysematous lesions in the lungs of 36 smokers (four with no emphysema, 13 with centriacinar emphysema (CAE), nine with panacinar emphysema (PAE), and 10 with a mixture (MIX) of both PAE and CAE). Mean lung airspace wall surface area per unit volume (AWUV) was calculated from at least six random blocks per lung and on histological sections immediately adjacent to those prepared for collagen measurement with a rapid scanning device (fast interval processor).

RESULTS

In non-smokers there was no significant correlation between the amount of collagen in the alveolar wall tissue and either mean lung AWUV or increasing patient age when amounts of collagen were expressed either per unit volume of distended lung (40 mm3 sample) or per unit surface area of airspace wall tissue. Smokers without emphysema had similar amounts of collagen to non-smokers. Lungs with PAE and MIX, but not CAE alone, contained significantly more collagen than normal when expressed per unit volume of airspace wall tissue whereas all groups, including CAE, contained significantly raised amounts of collagen when expressed per unit surface area.

CONCLUSIONS

There is no significant age related change in the collagen content of the lungs of non-smokers which suggests that, as AWUV is lost with age, the main collagenous framework is maintained. However, in smokers with emphysema there is a loss of airspace wall tissue in regions remote from the macroscopic lesions that is accompanied by a net increase in collagen mass. The greater accumulation of collagen in MIX lungs than in CAE lungs suggests a greater degree of structural damage, indicative of an alternative pathogenetic mechanism operating between the different types of emphysema. Our results suggest an active alveolar wall fibrosis in emphysema as a consequence of cigarette smoking. It is suggested that the definition of emphysema may require further revision to include such change.

Quantitative studies of human lung airspace wall in relation to collagen and elastin content

Biochemical determinations of the collagen and elastin content in 50 mm3 samples of human lung are presented in relation to morphometric measurements of lung structure, as the amount of alveolar wall surface area per unit volume (AWUV), on adjacent slices. There were no differences in AWUV values, collagen content (determined as hydroxyproline) or elastin content (determined as isodesmosine) between upper and lower lobes within a single lung. In a study of 102 samples from 9 smokers lungs with no evidence of macro- or microscopic emphysema (as estimated by AWUV measurement), there was a negative correlation between AWUV and the amounts of collagen or elastin per unit volume of inflated lung. The correlation was stronger when collagen and elastin content were expressed per unit area of alveolar wall. The negative correlation is interpreted as representing either the anatomical variation within the complex hierarchy of normal lung structure or possibly low levels of fibrosis in response to cigarette smoking.