Glasgow Prognostic Score Predicts Survival and Recurrence Pattern in Patients With Hepatocellular Carcinoma After Hepatectomy

BACKGROUND/AIM

The prognostic significance of the Glasgow Prognostic Score (GPS) on outcomes of liver resection for hepatocellular carcinoma (HCC) remains unclear; the aim of the study was to assess its significance.

PATIENTS AND METHODS

A total of 480 patients with HCC who underwent liver resection with curative intent at the Yokohama City University Hospital and Medical Center were enrolled in the study. Patients were classified into three groups: GPS-0, C-reactive protein (CRP) ≤1.0 mg/dl serum albumin ≥3.5 g/dl; GPS-1, CRP >1.0 mg/dl or serum albumin <3.5 g/dl; and GPS-2, CRP >1.0 mg/dl, serum albumin <3.5 g/dl. Prognostic factors for overall survival (OS) and disease-free survival (DFS) were analyzed retrospectively. The recurrence pattern was also investigated using GPS.

RESULTS

Of the 480 patients, 382 (79.6%), 81 (16.9%), and 17 (3.5%) were assigned to GPS-0, GPS-1, and GPS-2, respectively. Elevated GPS, indocyanine green retention rate at 15 min, and protein induced by vitamin K antagonist-II (PIVKA-II) were significantly associated with a poor OS. Elevated GPS, alpha-fetoprotein, and PIVKA-II were significantly associated with a poor DFS by multivariate analysis. The number of patients with liver-only recurrence in GPS-0, GPS-1, and GPS-2 was 179 (86.1%), 40 (78.4%), and 9 (69.2%), respectively. The number of patients with four or more intrahepatic metastases in the GPS-0, GPS-1, and GPS-2 groups, was 33 (17.9%), 11 (27.5%), and 8 (88.9%), respectively. The number of patients with four or more intrahepatic metastases in the GPS-2 group was significantly higher (p<0.001).

CONCLUSION

Preoperative GPS is a useful predictor of OS and recurrence pattern after liver resection with a curative intent for HCC.

Using Artificial Intelligence to Find the Optimal Margin Width in Hepatectomy for Colorectal Cancer Liver Metastases

Importance

In patients with resectable colorectal cancer liver metastases (CRLM), the choice of surgical technique and resection margin are the only variables that are under the surgeon's direct control and may influence oncologic outcomes. There is currently no consensus on the optimal margin width.

Objective

To determine the optimal margin width in CRLM by using artificial intelligence-based techniques developed by the Massachusetts Institute of Technology and to assess whether optimal margin width should be individualized based on patient characteristics.

Design, Setting, and Participants

The internal cohort of the study included patients who underwent curative-intent surgery for KRAS-variant CRLM between January 1, 2000, and December 31, 2017, at Johns Hopkins Hospital, Baltimore, Maryland, Memorial Sloan Kettering Cancer Center, New York, New York, and Charité-University of Berlin, Berlin, Germany. Patients from institutions in France, Norway, the US, Austria, Argentina, and Japan were retrospectively identified from institutional databases and formed the external cohort of the study. Data were analyzed from April 15, 2019, to November 11, 2021.

Exposures

Hepatectomy.

Main Outcomes and Measures

Patients with KRAS-variant CRLM who underwent surgery between 2000 and 2017 at 3 tertiary centers formed the internal cohort (training and testing). In the training cohort, an artificial intelligence-based technique called optimal policy trees (OPTs) was used by building on random forest (RF) predictive models to infer the margin width associated with the maximal decrease in death probability for a given patient (ie, optimal margin width). The RF component was validated by calculating its area under the curve (AUC) in the testing cohort, whereas the OPT component was validated by a game theory-based approach called Shapley additive explanations (SHAP). Patients from international institutions formed an external validation cohort, and a new RF model was trained to externally validate the OPT-based optimal margin values.

Results

This cohort study included a total of 1843 patients (internal cohort, 965; external cohort, 878). The internal cohort included 386 patients (median [IQR] age, 58.3 [49.0-68.7] years; 200 men [51.8%]) with KRAS-variant tumors. The AUC of the RF counterfactual model was 0.76 in both the internal training and testing cohorts, which is the highest ever reported. The recommended optimal margin widths for patient subgroups A, B, C, and D were 6, 7, 12, and 7 mm, respectively. The SHAP analysis largely confirmed this by suggesting 6 to 7 mm for subgroup A, 7 mm for subgroup B, 7 to 8 mm for subgroup C, and 7 mm for subgroup D. The external cohort included 375 patients (median [IQR] age, 61.0 [53.0-70.0] years; 218 men [58.1%]) with KRAS-variant tumors. The new RF model had an AUC of 0.78, which allowed for a reliable external validation of the OPT-based optimal margin. The external validation was successful as it confirmed the association of the optimal margin width of 7 mm with a considerable prolongation of survival in the external cohort.

Conclusions and Relevance

This cohort study used artificial intelligence-based methodologies to provide a possible resolution to the long-standing debate on optimal margin width in CRLM.

Role of the Intramural Vascular Network of the Extrahepatic Bile Duct for the Blood Circulation in the Recipient Extrahepatic Bile Duct Used for Duct-to-Duct-Biliary-Anastomosis in Living Donor Liver Transplantation

A duct-to-duct-biliary-anastomosis is the preferred biliary reconstruction technique in liver transplantation; biliary complications remain the major concerns for the technique. We examined the significance of the intramural vascular network of the extrahepatic bile duct (EBD) and its relevant vessels. We microscopically examined the axial sections of the EBD with 5 mm intervals of 10 formalin-fixed deceased livers. The luminal-areas of the 3 and 9 o’clock arteries correlated significantly and positively with the distance from the bifurcation of the right and left hepatic ducts (the 3 o’clock artery, r = 0.42, p < 0.001; the 9 o’clock artery, r = 0.39, p < 0.001); the ratios of the numbers of the intramural vessels to the areas of the corresponding sections of the EBD significantly correlated positively with the distance from the bifurcation of the right and left hepatic ducts (total vessels, r = 0.78, p < 0.001; arterioles, r = 0.52, p < 0.001; venules, r = 0.45, p < 0.001). This study demonstrated that there is a significant locoregional distributional heterogeneity of the intramural vessels among the EBD. The hepatic arteries neighboring the EBD primarily supply the blood flow to the EBD; thus, when the broader isolation of the EBD from the neighboring arteries is necessary, this locoregional distributional heterogeneity of the intramural vessels may render the EBD likely to suffer ischemia of the anastomotic site.

Surgical Indications for Huge Hepatocellular Carcinoma

BACKGROUND/AIM

This study aimed to retrospectively analyse adverse predictors to identify patients with huge hepatocellular carcinoma who were not appropriate candidates for hepatic resection.

PATIENTS AND METHODS

From 551 patients with hepatocellular carcinoma who underwent hepatectomy between 1992 and 2019, 92 were diagnosed with huge hepatocellular carcinoma (diameter >10 cm) and 115 were diagnosed with large hepatocellular carcinoma (diameter=5-10 cm). Clinical features and overall and disease-free survival rates were compared between the two groups.

RESULTS

Cumulative overall survival was significantly worse in the huge group than in the large group (p=0.035). In the huge group, multivariate analyses revealed that liver cirrhosis, multiple intrahepatic metastases (≥4), poor histological grade, and macroscopic portal vein invasion were significantly associated with poor prognosis.

CONCLUSION

We identified four adverse predictors of survival and determined that patients with two or more predictors are not appropriate candidates for straightforward hepatic resection.

A Classification System Specific for Recurrent Inguinal Hernia Following Open Hernia Surgery

BACKGROUND/AIM

Currently, there is no classification system specializing in recurrent inguinal hernia (RIH) after open-surgery. For this reason, in this study we proposed one so as to understand the causes of RIH.

PATIENTS AND METHODS

Recurrence of IH after suture-repair was classified either as the tissue-loosening (TL) or the tissue-disruption (TD) type. Recurrence after open-mesh-repair was classified according to the locational relation between the hernia-defect and the mesh, as follows: i) mesh-distant (MD), ii) para-mesh (PM), iii) mesh-migration (MM), and iv) unclassifiable (UC). Fifty-two RIHs in 48 patients were classified, using this system, and analyzed.

RESULTS

This system-based classification led to the identification of: i) MM in 11 lesions, ii) PM in 11, iii) MD in 10, iv) TL in 7, v) TD in 5, and vi) UC in 8 lesions. The median time to recurrence (MTR) was significantly shorter in patients who had previously undergone a mesh-repair (n=34) compared to those who had undergone a suture-repair (n=13) [Mesh-repair vs. suture-repair MTR: 1.6 years (0.1-20) vs. 30 years (15-72), p<0.001]. MTR was significantly shorter in the following order: i) MM [0.5(0.1-2.0)]), ii) PM [2.6(0.2-15)]), iii) MD [11(0.5-20)], iv) TD [20(15-30)], and v) TL [40(30-72)] (p<0.001).

CONCLUSION

This classification system helps understand the causes of RIH, leading to improved outcomes following open-surgery in the future.

Mutant KRAS as a prognostic biomarker after hepatectomy for rectal cancer metastases: Does the primary disease site matter?

BACKGROUND

The prognostic implication of mutant KRAS (mKRAS) among patients with primary disease in the rectum remains unknown.

METHODS

From 2000 to 2018, patients undergoing hepatectomy for colorectal liver metastases at 10 collaborating international institutions with documented KRAS status were surveyed.

RESULTS

A total of 834 (65.8%) patients with primary colon cancer and 434 (34.2%) patients with primary rectal cancer were included. In patients with primary colon cancer, mKRAS served as a reliable prognostic biomarker of poor overall survival (OS) (hazard ratio [HR]: 1.58, 95% CI 1.28-1.95) in the multivariable analysis. Although a trend towards significance was noted, mKRAS was not found to be an independent predictor of OS in patients with primary rectal tumors (HR 1.34, 95% CI 0.98-1.80). For colon cancer, the specific codon impacted in mKRAS appears to reflect underlying disease biology and oncologic outcomes, with codon 13 being associated with particularly poor OS in patients with left-sided tumors (codon 12, HR 1.56, 95% CI 1.22-1.99; codon 13, HR 2.10 95% CI 1.43-3.08;). Stratifying the rectal patient population by codon mutation did not confer prognostic significance following hepatectomy.

CONCLUSIONS

While the left-sided colonic disease is frequently grouped with rectal disease, our analysis suggests that there exist fundamental biologic differences that drive disparate outcomes. Although there was a trend toward significance of KRAS mutations for patients with primary rectal cancers, it failed to achieve statistical significance.

The Prognostic Impact of Primary Tumor Site Differs According to the KRAS Mutational Status: A Study By the International Genetic Consortium for Colorectal Liver Metastasis

OBJECTIVE

To examine the prognostic impact of tumor laterality in colon cancer liver metastases (CLM) after stratifying by Kirsten rat sarcoma 2 viral oncogene homolog (KRAS) mutational status.

BACKGROUND

Although some studies have demonstrated that patients with CLM from a right sided (RS) primary cancer fare worse, others have found equivocal outcomes of patients with CLM with RS versus left-sided (LS) primary tumors. Importantly, recent evidence from unresectable metastatic CRC suggests that tumor laterality impacts prognosis only in those with wild-type tumors.

METHODS

Patients with rectal or transverse colon tumors and those with unknown KRAS mutational status were excluded from analysis. The prognostic impact of RS versus LS primary CRC was determined after stratifying by KRAS mutational status.

RESULTS

277 patients had a RS (38.6%) and 441 (61.4%) had a LS tumor. Approximately one-third of tumors (28.1%) harbored KRAS mutations. In the entire cohort, RS was associated with worse 5-year overall survival (OS) compared with LS (39.4% vs 50.8%, P = 0.03) and remained significantly associated with worse OS in the multivariable analysis (hazard ratio 1.45, P = 0.04). In wild-type patients, a worse 5-year OS associated with a RS tumor was evident in univariable analysis (43.7% vs 55.5%, P = 0.02) and persisted in multivariable analysis (hazard ratio 1.49, P = 0.01). In contrast, among patients with KRAS mutated tumors, tumor laterality had no impact on 5-year OS, even in the univariable analysis (32.8% vs 34.0%, P = 0.38).

CONCLUSIONS

This study demonstrated, for the first time, that the prognostic impact of primary tumor side differs according to KRAS mutational status. RS tumors were associated with worse survival only in patients with wild-type tumors.

Performance of two prognostic scores that incorporate genetic information to predict long-term outcomes following resection of colorectal cancer liver metastases: An external validation of the MD Anderson and JHH-MSK scores

INTRODUCTION

Two novel clinical risk scores (CRS) that incorporate KRAS mutation status were developed: modified CRS (mCRS) and GAME score. However, they have not been tested in large national and international cohorts. The aim of this study was to validate the prognostic discrimination utility and determine the clinical usefulness of the two novel CRS.

METHODS

Patients undergoing hepatectomy for CRLM (2000-2018) in 10 centers were included. The discriminatory abilities of mCRS, GAME, and Fong CRS were evaluated using Harrell's C-index and Akaike's Information Criterion.

RESULTS

In the entire cohort, the C-index of the GAME score (0.61) was significantly higher than those of Fong score (0.57) and mCRS (0.54), while the C-Index of mCRS was significantly lower than that of Fong score. When we compared the models in the various geographical regions, the C-index of GAME score was significantly higher than that of mCRS in North America, Europe, and South America. The AIC of Fong score, mCRS, and GAME score were 14 405, 14 447, and 14 319, respectively.

CONCLUSION

In conclusion, using the largest and most heterogenous population of CRLM patients with known KRAS status, this independent, external validation demonstrated that the GAME score outperforms both the traditional Fong score and mCRS.

Subcutaneous switching suture technique for hernia defect closure during laparoscopic ventral and incisional hernia repair

INTRODUCTION

A vertical penetration of the thread through the abdominal wall for the hernia defect closure in laparoscopic ventral/incisional hernia repair (LVIHR) is difficult especially in the large defect cases when applying the existing techniques.

MATERIALS

Sixteen LVIHRs were performed using the suture technique for defect closure we newly developed.

SURGICAL TECHNIQUE

With the subcutaneous switching, our technique only requires the suture-passer and easily enables the vertical penetration of the thread through the abdominal muscular wall even in the large defect cases.

DISCUSSION

The defect closure in LVIHR tends to be complicated in the large defect cases. Thus, we devised this technique for the easy, reliable, and firm closure even in the large defect cases. Although the sample size was currently very small, we consider that the favorable outcomes have been obtained through our technique because any noticeable complications, such as mesh bulging or recurrence, have not been observed currently.

Treatment of acute exacerbation of liver-cirrhosis-associated portal vein thrombosis with direct-acting oral anticoagulant, edoxaban, used as an initial treatment in the early postoperative period after abdominal surgery: a case report

Background

Cirrhosis-associated portal vein thrombosis (CA-PVT) has been reportedly observed in 5–30% of cirrhotic patients. Moreover, the acute exacerbation of CA-PVT is likely to occur after certain situations, such as a status after abdominal surgery. Safety and efficacy of the direct-acting oral anticoagulant (DOAC) used for cirrhotic patients have been being confirmed. However, use of the DOAC as an initial treatment for CA-PVT appears still challenging especially in the early postoperative period after major surgery in terms of unestablished efficacy and safety in such occasion.

Case presentation

We herein report a case of the acute exacerbation of CA-PVT in the early postoperative period after abdominal surgery, which was successfully treated with DOAC, edoxaban used as an initial treatment. The patient was a 79-year-old Japanese male with alcoholic cirrhosis. The patient suffered choledocholithiasis and had a mural chronic CA-PVT extending from the superior mesenteric vein to the portal trunk. He underwent open cholecystectomy and choledochotomy. Early postoperative clinical course was uneventful except for abdominal distension due to ascites diagnosed on postoperative day (POD)7 when hospital discharge was planned. Contrast enhancement computed tomography (CE-CT) taken on POD 7 revealed the exacerbation of the CA-PVT. Despite recommendation for extension of hospital admission with low molecular weight heparin treatment, the patient strongly hoped to be discharged. Unwillingly, we selected DOAC, edoxaban, as an initial treatment, which was commenced the day after discharge (POD8). As a result, the remarkable improvement of the exacerbated CA-PVT was confirmed by the CE-CT taken on POD21. Any bleeding complications were not observed. Although a slight residue of the CA-PVT remains, the patient is currently doing well 4 years after surgery and is still receiving edoxaban. Any adverse effects of edoxaban have not been observed for 4 years.

Conclusions

A case of successful treatment of the acute exacerbation of CA-PVT with edoxaban was reported. Moreover, edoxaban has been safely administered in a cirrhotic patient for 4 years. The findings obtained from the present case suggest that DOAC can be used as an initial treatment for CA-PVT even in early postoperative period after major abdominal surgery.

Predictive Ability of Preoperative PT-INR and Postoperative MCP1 for Post-hepatectomy Liver Failure

BACKGROUND

We sought a diagnostic tool using perioperative variables that might predict post-hepatectomy liver failure (PHLF).

PATIENTS AND METHODS

In 68 patients undergoing major hepatectomy, data on inflammatory markers and coagulation factors were prospectively collected and were compared between patients with International Study Group of Liver Surgery definition grade B/C PHLF (LF group) and those without LF (non-LF group).

RESULTS

Preoperatively, the LF group (n=9; 13.2%) had a lower platelet count and a disintegrin-like and metalloproteinase with thrombospondin type 1 motifs 13 (ADAMTS13) activity and a higher prothrombin time-International Normalized Ratio (PT-INR) than the non-LF group. On postoperative day 1, the LF group had significantly higher serum interleukin 6 (IL6), C-C motif chemokine ligand 2 (CCL2), and IL10 levels than the non-LF group. The logistic regression model that included preoperative PT-INR and CCL2 on postoperative day 1 predicted grade B/C PHLF with 100% sensitivity and 89.8% specificity.

CONCLUSION

Our findings suggest that the combination of preoperative PT-INR and CCL2 on postoperative day 1 can predict PHLF earlier and precisely after major hepatectomy.

Superiority of Sepsis-3 to Sepsis-2 in the Early Detection of Severe Early Postoperative Sepsis After Living Donor Liver Transplantation

BACKGROUND

To date, the utility of Sepsis-3 compared to Sepsis-2 in living donor liver transplantation (LDLT) recipients has not been evaluated. We assessed the utility of Sepsis-3 compared to Sepsis-2 and verified the following hypotheses: 1. Sepsis-3-based sepsis (S3BS) corresponds to Sepsis-2-based severe sepsis (S2BSS), and 2. S3BS enables earlier diagnosis of early postoperative sepsis (within 21 postoperative days; EPoS) compared to S2BSS.

METHODS

We evaluated 66 LDLT recipients in our institution. Patients with EPoS, who were diagnosed with S3BS and S2BSS, were extracted, and the postoperative day of diagnosing S3BS and S2BSS was identified.

RESULTS

EPoS was diagnosed in 14 patients with S3BS (21.2%) and in 15 with S2BSS (22.7%). All but 1 patient with S2BSS corresponded to those with S3BS, with 98.4% overlap. Among the overlapping 14 patients, the comparison between the postoperative days when S3BS and S2BSS occurred demonstrated that S3BS was diagnosed earlier in 7 patients (50%) and on the same day in 4 (28.6%), and S2BSS was diagnosed earlier in 3 (21.4%). Especially in cases with a change in the sequential organ failure assessment (SOFA) immediately after S3BS onset compared to before (ΔSOFA) of ≥ 4 points (n = 6), S3BS was diagnosed earlier in 5 cases (83.3%); in cases with ΔSOFA of 2 to 3 points (n = 8), S3BS was diagnosed earlier only in 2 cases (25.0%). Thus, early diagnosis of S3BS was significantly more common in cases with ≥ 4 points of ΔSOFA (P = .02).

CONCLUSIONS

S3BS nearly corresponds to S2BSS and can enable earlier detection of EPoS, especially with a high ΔSOFA.

The optimal cut-off values for tumor size, number of lesions, and CEA levels in patients with surgically treated colorectal cancer liver metastases: An international, multi-institutional study

BACKGROUND AND OBJECTIVES

Despite the long-standing consensus on the importance of tumor size, tumor number and carcinoembryonic antigen (CEA) levels as predictors of long-term outcomes among patients with colorectal liver metastases (CRLM), optimal prognostic cut-offs for these variables have not been established.

METHODS

Patients who underwent curative-intent resection of CRLM and had available data on at least one of the three variables of interest above were selected from a multi-institutional dataset of patients with known KRAS mutational status. The resulting cohort was randomly split into training and testing datasets and recursive partitioning analysis was employed to determine optimal cut-offs. The concordance probability estimates (CPEs) for these optimal cut offs were calculated and compared to CPEs for the most widely used cut-offs in the surgical literature.

RESULTS

A total of 1643 patients who met eligibility criteria were identified. Following recursive partitioning analysis in the training dataset, the following cut-offs were identified: 2.95 cm for tumor size, 1.5 for tumor number and 6.15 ng/ml for CEA levels. In the entire dataset, the calculated CPEs for the new tumor size (0.52), tumor number (0.56) and CEA (0.53) cut offs exceeded CPEs for other commonly employed cut-offs.

CONCLUSION

The current study was able to identify optimal cut-offs for the three most commonly employed prognostic factors in CRLM. While the per variable gains in discriminatory power are modest, these novel cut-offs may help produce appreciable increases in prognostic performance when combined in the context of future risk scores.

Reduction of gender-associated M2-like tumor-associated macrophages in the tumor microenvironment of patients with pancreatic cancer after neoadjuvant chemoradiotherapy

PURPOSE

This study aimed to investigate gender-dependent antitumor immune response to neoadjuvant chemoradiotherapy (NACRT) in pancreatic ductal adenocarcinoma (PDAC) patients.

METHODS

This study enrolled 58 patients (25 females and 33 males) with borderline resectable PDAC who underwent R0 surgical resection after NACRT. The resected tumor specimens were analyzed for tumor-associated macrophages (TAMs); tumor-infiltrating lymphocytes (CD8+ and CD4+ T cells); regulatory T cells; and IRF-5-expressing cells using immunohistochemical staining for CD163, CD204, CD8, CD4, Foxp3, and IRF-5 antigen. The relationship between clinicopathological features and clinical outcomes was evaluated using multivariate Cox proportional hazard analysis.

RESULTS

Females had longer overall survival (P = .044) and relapse-free survival (P = .044) than males. The CD204+ TAM number was significantly lower in females than in males (P = .009). No significant difference occurred between female and male patients in other tumor-infiltrating immune cells. IRF-5+ cell number was significantly higher in female patients (P = .002). Negative correlation occurred between CD204+ cells and IRF-5-positive cells (P = .003, r = -.385).

CONCLUSIONS

Female gender was an independent prognostic factor possibly due to the greater reduction in CD204+ TAM infiltration in tumors after NACRT. The beneficial effects of NACRT on TAMs' infiltration might be associated with gender-dependent IRF-5 expression.

Completely laparoscopic repair for recurrent inguinal hernia that developed after open posterior mesh repair

Surgeons tend to avoid performing completely laparoscopic repair (CLR) for recurrent inguinal hernia (RIH) that developed after the open posterior mesh repair (OPMR). For many, totally extraperitoneal repair or transabdominal preperitoneal repair after OPMR seems difficult because the previously placed mesh may pose an obstacle during the exfoliation of the parietal peritoneum. Moreover, these procedures could cause chronic pain if the "trapezoid of disaster" is injured. In this small case series, we describe our operative technique for CLR for RIH after OPMR, including modified transabdominal preperitoneal repair and modified intraperitoneal onlay mesh repair. The short-term and midterm outcomes of this procedure are also reported. Although we recognize the need for further analysis involving many more cases and a longer follow-up period, we will continue to perform CLR for RIH after OPMR because the results of this small case series were favorable.

Surgical intervention for portal hypertension caused by oxaliplatin-based chemotherapy: a case report and a review of literature regarding radiological and/or surgical interventions for oxaliplatin-associated portal hypertension

A 63-year-old man showed massive ascites, massive pleural effusion, severe lower-extremity edema, and repeated esophageal variceal bleeding. Two-year previously, he received 13-courses of oxaliplatin-based chemotherapy (OBC) followed by associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) for multiple colorectal cancer liver metastases but developed a solitary remaining liver metastasis and multiple lung metastases 2 months after the ALPPS, for which multiple regimens of chemotherapy were conducted. The symptoms were considered attributable to the OBC-associated portal-hypertension. Water-retention symptoms were mitigated by the use of tolvaptan but the variceal bleeding necessitated frequent endoscopic treatments and disallowed restarting antineoplastic treatment. Transjugular intrahepatic portosystemic shunt (TIPS) was considered undesirable because TIPS in this patient might have prohibited future repeat hepatectomy. Thus, the patient underwent splenectomy and surgical portosystemic shunting. Since then, the portal-hypertension symptoms were completely resolved. Thereafter, chemotherapy was able to be recommenced. Moreover, repeat hepatectomy was performed. A literature review demonstrated that radiological and/or surgical interventions for the OBC-associated portal-hypertension have been reported in 31 cases to date. However, this report is the first to show a case of successful treatment of the OBC-associated portal-hypertension with splenectomy and surgical portosystemic shunting, which allowed subsequent chemotherapy followed by repeat hepatectomy.

Impact of intramuscular adipose tissue content on short- and long-term outcomes of hepatectomy for colorectal liver metastasis: a retrospective analysis

Background

Numerous reports regarding sarcopenia have focused on the quantity of skeletal muscle. In contrast, the impact of the quality of skeletal muscle has not been well investigated.

Methods

A retrospective analysis of 115 patients who underwent initial hepatectomy for colorectal liver metastasis between January 2009 and December 2016 in our hospital was performed. Intramuscular adipose tissue content (IMAC) was used to evaluate the quality of skeletal muscle by analysing computed tomography (CT) images at the level of the umbilicus. The impact of poor skeletal muscle quality on short-term and long-term outcomes after hepatectomy for colorectal liver metastasis was analysed.

Results

Patients were divided into two groups (high IMAC and normal IMAC) according to their IMAC values, and their backgrounds were compared. There were no significant differences in most factors between the two groups. However, both body mass index (P = 0.030) and the incidence of postoperative complications of Clavien-Dindo grade 3 or worse (P = 0.008) were significantly higher in the high-IMAC group. In multivariate analyses, an operative blood loss > 600 ml (P = 0.006) and high IMAC (P = 0.008) were associated with postoperative complications of Clavien-Dindo grade 3 or worse. Overall survival and recurrence-free survival were significantly lower (P < 0.001 and P = 0.045, respectively) in the high-IMAC group than in the normal IMAC group. In multivariate analyses for poor overall survival, high IMAC was associated with poor overall survival (P < 0.001).

Conclusions

IMAC is a prognostic factor for poor short- and long-term outcomes in patients with colorectal liver metastasis.

Efficacy of prolonged elemental diet therapy after pancreaticoduodenectomy for pancreatic ductal adenocarcinoma: A pilot prospective randomized trial (UMIN000004108)

BACKGROUNDS AND AIMS

This randomized clinical trial examined efficacy of prolonged elemental diet (ED) therapy after pancreatoduodenectomy (PD) for pancreatic ductal adenocarcinoma (PDAC), which often causes postoperative malnutrition leading to worsened short- and long-term outcomes.

METHODS

Thirty-nine patients with PDAC receiving PD was randomly assigned to prolonged ED group (PEDG) and control group (CG). Fat-free ED (Elental®, EA Pharma CO., Ltd., Tokyo, Japan) via tube jejunostomy was initiated on postoperative day 1 and increased to maintain with 600 kcal/day in addition to oral intake. ED was discontinued if sufficient oral intake was achieved in CG but continued during 3 postoperative months in PEDG. Primary outcome was complication necessitating readmission. Secondary outcomes were nutritional parameters, relative dose intensity (RDI) in cases of adjuvant chemotherapy, and survival outcomes.

RESULTS

Twenty patients were assigned to CG and 19 to PEDG. Cumulative post-discharge readmission rate was significantly lower in PEDG than in CG (PEDG vs CG; 12.6% vs 43.7% at 12-post-discharge-month; p = 0.018). Total calorie and ED-derived protein intakes were significantly larger in PEDG than in CG up to 3-postoperative-month but thereafter similar among groups. Lymphocyte counts were significantly increased and neutrophil-to-lymphocyte-ratio (NLR) was significantly reduced in PEDG than in CG at 2-, 3-, and 6-postoperative-month. However, other outcome measures did not differ among groups.

CONCLUSION

This trial failed to show survival benefit of prolonged ED therapy but demonstrated its favorable effect on increased lymphocyte counts, reduced NLR, and prevention of complications necessitating readmission, those which may lead to survival benefit with some modifications.

Our Rationale of Initiating Neoadjuvant Chemotherapy for Hilar Cholangiocarcinoma: A Proposal of Criteria for "Borderline Resectable" in the Field of Surgery for Hilar Cholangiocarcinoma

BACKGROUND

The concept of "borderline resectable" was recently introduced to the field of surgery for pancreatic cancer, and surgical outcomes for this disease with extremely dismal prognosis have improved since the introduction of this concept. However, no such concept has yet been introduced to the field of surgery for hilar cholangiocarcinoma (HCca).

AIM

To determine a definition and criteria for "borderline resectable" in the field of surgery for HCca.

PATIENTS AND METHODS

Retrospective analysis of 88 patients undergoing curative-intent surgery for HCca at our institution between May 1992 and December 2008 to clarify independent prognostic factors.

RESULTS

Survival outcomes were obtained for these 88 patients, with a 5-year overall survival rate of 31.8%. Independent factors predictive of cancer death were determined by multivariate analysis to be the presence of regional lymph node metastasis (LNM) and pathological confirmed vascular invasion (VI). Cumulative survival rates of 23 patients with both LNM and VI who underwent surgery were significantly worse than those of the remaining 65 surgically treated patients and similar to those of 26 patients who were considered to have unresectable disease and treated with non-surgical multidisciplinary treatment during the same study period.

CONCLUSION

Outcomes of surgery for cases of HCca showing regional LNM and VI were no better than those of non-surgical treatment for unresectable disease. Coexistence of these two factors indicates oncologically dismal condition and thus such cases should be considered "borderline resectable." Treatments additional to surgery are required for "borderline resectable" cases to obtain better outcomes.

A Simple and Easily Reproducible Model of Reversible Obstructive Jaundice in Rats

BACKGROUND/AIM

Cholangiocarcinoma and pancreatic carcinoma are major malignancies that cause obstructive jaundice (OJ). This study aimed to develop a simple and easily reproducible rat model of reversible OJ (ROJ).

MATERIALS AND METHODS

OJ was induced by clamping the common bile duct (CBD) using a U-shaped titanium hemoclip and its base was attached by ligation using 2-cm long 4-0 polypropylene suture. An anti-adhesive sheet was placed around the CBD. OJ was mitigated by pulling the suture to remove the clip under laparotomy 3 days later. Serum chemistry and liver histopathology were compared between the ROJ group and sham surgery (SH) groups.

RESULTS

Three days after inducing OJ, serum total bilirubin, aspartate aminotransferase, and alanine aminotransferase were remarkably elevated in the ROJ group and thereafter reduced significantly after mitigating OJ. Similar findings were confirmed by histopathology.

CONCLUSION

Our rat model of reversible OJ was considered simple and easily reproducible.

Surgical and histological boundary of the hepatic hilar plate system: basic study relevant to surgery for hilar cholangiocarcinoma regarding the "true" proximal ductal margin

BACKGROUND

We sought to expand the clinico-anatomical limit of the proximal ductal margin (Limit-PDM) for resectability of hilar cholangiocarcinoma (HCCA).

METHODS

The practical boundary of the hilar plate (PBHP) was defined as the location where the bile duct (BD) could not be isolated by dissection. The distance between PBHP and two well-known clinical landmarks of Limit-PDM, the right edge of the bifurcation of the anterior and posterior branch of the right portal vein (Posterior-Landmark) and the left edge of the umbilical portion of the portal vein (Left-Landmark), and histological features around the PBHP were assessed using 55 adult cadaver livers.

RESULTS

BD was almost always isolatable beyond the traditional clinical landmarks. The median distance was 6.9 mm (interquartile range [IQR] 6.0-8.3 mm) between the PBHP and the Posterior-Landmark, and 8.9 mm (IQR 6.7-10.2 mm) between the PBHP and the Left-Landmark. Histologically, the sheath surrounding the portal triad was loose, thick with few elastic fibers and small arteries near the hepatic hilum. Near the PBHP, the sheath was dense, thin, and abundant with elastic fibers and small arteries.

CONCLUSIONS

Limit-PDM is more peripheral than the traditional clinical landmark-based margin and histological transition near the PBHP was revealed.

Higher Tumor Burden Neutralizes Negative Margin Status in Hepatectomy for Colorectal Cancer Liver Metastasis

OBJECTIVE

The aim of this study was to examine if the prognostic significance of margin status in hepatectomy for colorectal cancer liver metastasis (CRLM) varies for different levels of tumor burden because hepatectomy indications for CRLM have been recently expanded to include patients with a higher tumor burden in whom achieving an R0 resection is difficult.

METHODS

Clinicopathological variables in an exploration cohort of 290 patients receiving hepatectomy in Japan for CRLM were investigated. R0 resection was defined as a margin width > 0 mm. Tumor burden was assessed using the recently introduced Tumor Burden Score (TBS), which was calculated as TBS² = (maximum tumor diameter in cm)² + (number of lesions)². The principal findings were validated using a cohort from the United States.

RESULTS

R1 resection rates significantly increased as TBS increased: 4/86 (4.7%) in patients with TBS < 3, 29/171 (17.0%) in patients with TBS ≥ 3 and < 9, and 9/33 (27.3%) in patients with TBS ≥ 9 (p < 0.001). R0 resection was significantly superior to R1 resection in patients with TBS ≥ 5; however, this was not the case for TBS ≥ 6, as confirmed by both univariate and multivariate analyses. Furthermore, prehepatectomy chemotherapy was associated with significantly improved survival for patients with TBS ≥ 8. Analysis of the validation cohort yielded similar results.

CONCLUSIONS

R0 resection appeared to have a positive impact on prognosis among patients with low tumor burden; however, this was not the case for patients with high tumor burden. As such, systemic treatment, in addition to surgery, may be central to achieving satisfactory outcomes in the latter patient population.

Predictive factors for bile leakage after hepatectomy for hepatic tumors: a retrospective multicenter study with 631 cases at Yokohama Clinical Oncology Group (YCOG)

BACKGROUND

International Study Group of Liver Surgery (ISGLS) proposed the standardized definition for bile leakage (BL) after hepatectomy (Hx) at 2011 to precisely perceive incidence and predictive factors of this critical condition.

METHODS

We conducted a multicenter retrospective study using the ISGLS definition of BL after Hx.

RESULTS

Perioperative data regarding 631 patients undergoing elective Hx for hepatic tumors without biliary reconstruction performed between January 2009 and December 2011 were analyzed. BL was observed in 30 patients (4.8%). (Grade A, 8 (1.3%); B, 21(3.3%); C, 1 (0.2%)). Five independent predictors (diagnosis of liver metastases, prolonged operation, high risk procedures defined as Hx with broad exposure of the hilar Glissonean sheath, low platelet count and high serum total bilirubin on postoperative day 1) for grade B/C BL were elucidated by the multivariate analysis. When the study cohorts were divided into groups by number of accompanying these predictors, the more the accompanying independent predictors, the higher the incidence of BL. Notably, incidence of BL exceeded 40% in patients with four or more of these predictors.

CONCLUSIONS

Risk stratification for BL after Hx can be achievable using independent predictors clarified in this study. However, proper management for high risk patients remains to be elucidated.

[Remarkable Response to Trastuzumab Observed in a Case of Gastric Cancer with HER2-Negative Conversion]

A 64-year-old woman was diagnosed with advanced gastric cancer with solitary liver metastasis. Although the HER2 status of the tumor was IHC2+, no further examination for HER2 status using FISH was performed. Four courses of S-1 and cisplatin chemotherapy were administered. The primary lesion and metastatic lesion were confirmed to have partially regressed. After 4 courses of chemotherapy, an open total gastrectomy, D2 dissection, pancreatosplenectomy, and posterior segmental hepatectomy were performed. Her postoperative course was uneventful. On histopathology, cancer cells were found in the resected stomach and resected liver. However, the HER2 statuses of the resected specimens were negative. After discharge, she received S-1 therapy for 1 year. Upon evaluation 1 year and 1 month postoperatively, the tumor marker CA19-9 was elevated. An enhanced CT scan showed multiple lung metastases and lymph node metastases in the pancreatic tail. Three courses of XELOX therapy(capecitabine and oxaliplatin)were administered. However, tumor marker levels continued to increase, and the metastasis continued to enlarge. Although the HER2 status of the resected site was negative, the HER2 status of the biopsy specimen before chemotherapy was positive on FISH. Therefore, weekly paclitaxel and trastuzumab therapy was initiated and repeated for 6 courses, after which an enhanced CT showed significant reduction(nearly CR)of multiple lung metastases and lymph node metastases. This suggests that HER2-negative conversion had occurred at the resected site. However, the HER2 status of the metastatic sites was considered positive.

Significance of Vascular Resection and Reconstruction in Surgery for Hilar Cholangiocarcinoma: With Special Reference to Hepatic Arterial Resection and Reconstruction

PURPOSE

The aim of this study was to assess the efficacy of combined resection and reconstruction (CRR) of the hepatic artery (HA) in surgery for hilar cholangiocarcinoma (HC).

MATERIALS AND METHOD

Among 172 patients who underwent surgical resection for HC, the following three groups were defined according to the type of vascular reconstruction: VR(-) group, in which neither CRR of the portal vein (PV) nor HA was performed (n = 74); VR-PV group, in which only CRR of the PV was required (n = 54); and VR-A group, in which CRR of the HA was performed either with or without CRR of the PV (n = 44). Clinicopathological variables and clinical outcomes were compared among the three groups.

RESULTS

Although the VR-A group showed significantly more advanced disease than other groups, the R0 resection rate was comparable among the three groups (VR(-), 74 %; VR-PV, 80 %; VR-A, 80 %). The 5-year disease-specific survival rate was also comparable among the three groups (VR(-), 45.6 %; VR-PV, 51.2 %; VR-A, 22.3 %), but tended to be worse in the VR-A group than in the other groups. A similar trend was observed in morbidity rate. Lymph node metastasis was more frequent in the VR-A group (59 %) than in the other groups (VR(-), 33.8 %; VR-PV, 50 %). In the VR-A group, lymph node metastasis (p = 0.004) and adjuvant chemotherapy (p = 0.006) were determined to represent independent prognostic factors for survival according to multivariate analysis.

CONCLUSION

CRR of the HA was considered efficacious in selected patients; however, long-term outcomes of the VR-A group seem unsatisfactory. Treatments additional to surgery may be necessary in cases requiring CRR of the HA.

Hepatocellular carcinoma incidentally detected at second hepatectomy for repeated colorectal liver metastasis in a patient with hepatitis C virus-related cirrhosis: a case report

Background

It has been reported that liver metastasis rarely occurs in a cirrhotic/hepatitic liver. Thus, coexistence of liver metastasis and hepatocellular carcinoma has been scarcely reported. To the best of our knowledge, there are no cases with hepatocellular carcinoma, which developed during an observational period after hepatectomy for colorectal liver metastasis, in the worldwide English literature. Here we present a case of hepatocellular carcinoma which occurred during a period between the first and second hepatectomy for repeated colorectal liver metastasis.

Case presentation

A 65-year-old Japanese woman underwent rectal resection for advanced rectal cancer. Hepatitis C cirrhosis was diagnosed at that time and antiviral therapy was offered but rejected because of socioeconomic reasons. At the age of 68, she developed two colorectal liver metastases originating from the rectal cancer, which were treated by local ablation and partial hepatectomy. At the age of 71, solitary recurrent colorectal liver metastasis was observed adjacent to the previously ablated lesion in segment 4, and thus segmentectomy 4 was performed. During surgery, a small tumor in segment 8 was incidentally identified. Taking into account her history, the tumor was considered to be recurrent colorectal liver metastasis and it was extirpated by partial hepatectomy. However, the segment 4 tumor was diagnosed as recurrent colorectal liver metastasis on the basis of histological findings and the segment 8 tumor was diagnosed as hepatocellular carcinoma. Although she had a cut surface abscess postoperatively, she was discharged from hospital 21 days after the surgery and is currently doing well 18 months after the second hepatectomy. She is currently receiving interferon and ribavirin therapy to eliminate hepatitis C virus.

Conclusions

If antiviral therapy was performed earlier for the present case and viral elimination was achieved, hepatocellular carcinoma might not have developed. This case reemphasizes the importance of antiviral therapy for preventing carcinogenesis of hepatocellular carcinoma in patients with viral hepatitis even if they have other cancers.

Blunt penetration technique for treatment of a completely obstructed anastomosis after rectal resection: a case report

Introduction

We present a case of completely obstructed anastomosis after rectal resection which was nonsurgically and successfully treated with a blunt penetration technique using a commonly used device for transanal ileus drainage. The technique we used in this case has not been previously reported.

Case presentation

A 79-year-old Japanese man underwent redo rectal resection for completely separated anastomosis which was caused by anastomotic leakage after a sigmoidectomy performed 3 years previously that was remedied by diverging ileostomy. Immediately after the redo surgery, fluoroscopy showed good passage through the colorectal anastomosis but no anastomotic leakage. However, fluoroscopy and colonoscopy prior to the ileostomy takedown showed complete obstruction of the anastomosis. Unlike usual anastomotic strictures, the lumen between colon oral and rectum anal to the anastomosis was completely discontinued by a membranous structure. Therefore, a conventional balloon dilatation technique was unsuitable for this condition. We applied a blunt penetration technique using a commercially available device designed as a transanal drainage system for obstructing colorectal cancer to restore the continuity between the colon oral and rectum anal to the anastomosis. After restoring the continuity, we performed conventional balloon dilatation for the anastomosis and successfully treated the anastomotic obstruction. Subsequently, the patient underwent ileostomy takedown and is currently doing well 12 months after the ileostomy takedown.

Conclusions

The penetration technique we applied is easy and less stressful to adopt because it does not require usage of materials specialized for other particular purposes. Furthermore, we believe that this technique is superior in safety to other reported methods for this condition even if applied in the wrong direction because this technique does not utilize electrocision or sharp needle puncture.

Small hepatocellular carcinoma with ring calcification: A case report and literature review

Ring calcification in untreated hepatocellular carcinoma (HCC) is extremely rare, with only 3 previously reported cases in the English-language literature. A case of HCC with ring calcification was reported in this paper. Additionally, 3 previously reported cases of HCC with ring calcification were reviewed. In 3 of these 4 cases (including our case), surgery was performed. Although the size of the ring-calcified lesion ranged from 3.0-3.7 cm in previously reported cases, the size was only 1 cm in ours. The differentiation of the tumor was moderate in the 2 previously reported cases in the histological findings and poor in ours. In spite of their poor differentiation for their sizes, these tumors showed no early enhancement in dynamic computed tomography. All calcified tumors showed a thick fibrous capsule and extensive necrosis histologically. Ring calcification was considered to result from a circulatory disturbance caused by the imbalance between the less abundant arterial blood flow and high inner pressure induced by either the thick fibrous capsule or vigorous proliferation due to the poor differentiation. Ring calcification in untreated HCC may suggest a lower differentiation of the tumor. Even if its size is small, hepatic resection should be performed for any tumor with ring calcification because poor differentiation is considered to be one of the risk factors for recurrence after local ablation therapy, including radio frequency ablation.

Chylous ascites occurring after low anterior resection of the rectum successfully treated with an oral fat-free elemental diet (Elental(®))

Chylous ascites occurring after abdominal surgery is rare. Despite being potentially critical, there is no definite treatment guideline because of its rarity. Here we present a case of massive chylous ascites occurring after rectal surgery which was successfully treated with an oral fat-free elemental diet (ED). A 67-year-old man underwent low anterior resection with para-aortic lymphadenectomy for advanced rectal cancer. Early postoperative course was uneventful and the patient was discharged from hospital 10 days after surgery; however, after discharge, abdominal distension rapidly developed. Abdominal computed tomography (CT) performed 3 weeks after surgery revealed massive ascites and laboratory findings showed remarkable hypoproteinemia and lymphopenia. Urgent diagnostic paracentesis showed the ascites to be a white milky fluid containing high levels of triglycerides (564 mg/dl), leading to a diagnosis of chyloperitoneum. Daily nutrition of the patient was entirely with a fat-free ED (30 kcal/kg/day of Elental(®), Ajinomoto Pharmaceutical Co. Ltd, Tokyo, Japan). After the initiation of oral Elental(®), abdominal distension, hypoproteinemia, and lymphopenia gradually improved. Abdominal CT performed 7 weeks after surgery showed no ascitic fluid in the abdomen, and thereafter a normal diet was initiated. Since then, no relapse of chyloperitoneum has been proven. As a result, the chylous ascites was successfully treated in the outpatient clinic.

Is lymph-node micrometastasis in gallbladder cancer a significant prognostic factor?

BACKGROUND/AIMS

The purpose of our study was to investigate prognostic significance of lymph-node micrometastasis in gallbladder carcinoma.

METHODOLOGY

In total, 1,094 lymph nodes from 41 patients who had undergone radical resection with lymph-node dissection, including para-aortic lymph nodes were stained with hematoxylin and eosin (H&E) and immunostained with anti-cytokeratin 7/8 antibody. Micrometastasis in each lymph node was defined as tumor cells that were detectable only by immunohistochemical evaluation and were not detected by H&E staining.

RESULTS

Metastases were detected in 163 lymph nodes (14.9%) by H&E staining. Micrometastases were found in 25 of the remaining lymph nodes (2.3%). Among 24 patients with lymph node metastasis based on the H&E staining, 12 had micrometastases. Of the 17 patients in whom lymph-node metastasis was not detected by the H&E staining, one was found to have micrometastasis. Micrometastasis correlated significantly with lymph node metastasis on H&E staining and pN (Tumor-Node-Metastasis 5th ed.). On multivariate analysis of data from 17 node-positive patients who underwent curative resection, micrometastasis and microscopic venous invasion were significant prognostic factors.

CONCLUSIONS

Our findings suggest that micrometastasis might be traces of scatter of cancer cells to the whole body rather than an event in an initial stage of the metastasis.

Pathogenesis in ABO incompatible liver transplantation: a clinicohistological evaluation of four patients

The aim of this study was to clarify the pathogenesis of antibody-mediated rejection (AMR) of ABO-incompatible liver transplantation (ABO-I-LT). We investigated, within one month of surgery, the clinical courses of 10 patients who received ABO-I-LT. We encountered four cases of AMR, which were classified into two groups according to the stage of the AMR: early (within the first 14 postoperative days [PODs]) or late (after the 14th POD). There were three patients in the early stage, and one patient in the late stage. Three early-stage AMR patients had both hyperbilirubinemia and thrombocytopenia within one month after LDLT, but the one late-stage AMR patient had neither. On liver biopsy, hemorrhagic infiltration was seen more frequently in the early-stage AMR patients than in the patient with late-stage AMR. Plasma exchange combined with a large amount of gamma-globulin bolus infusion therapy was effective in the three early-stage patients, but the late-stage AMR was controlled by antibiotic treatment. This study showed that the early-stage AMR resulted from the antigen-antibody reaction of ABO-blood-group antigens, while the late-stage AMR may have been caused by an infection.

Analysis of gene expression profiles in fatal hepatic failure after hepatectomy in mice

BACKGROUND

We developed 90%-hepatectomized mice that were the fatal model, and analyzed the gene expression profiles using a complementary DNA (cDNA) microarray to clarify the mechanisms of hepatic failure after excessive hepatectomy.

MATERIALS AND METHODS

Ribonucleic acid (RNA)s from the remnant hepatic tissue of 70%- and 90%-hepatectomized mice were labeled with fluorescent dyes, and hybridized to the Riken set of 39,168 full-length enriched mouse cDNA arrays. The gene expression profiles in 90%- and 70%-hepatectomized mice were analyzed by scanning date for fluorescent dye signals.

RESULTS

The down-regulated genes in 90%-hepatectomized mice were genes activating extracellular matrix (ECM) remodeling (matrix metalloproteinases, laminins, and integrins), genes related to cytokines (tumor necrosis factor α converting enzyme, and Janus kinase 3) that were related to the priming, genes related to growth factor (heparin-binding epidermal growth factor-like growth factor and others), and genes promoting cell cycle progression (cyclin D1, D2, and E2) that were related to the progression of hepatocytes. The up-regulated genes were genes inhibiting ECM remodeling [plasminogen activator inhibitors (PAIs)].

CONCLUSIONS

Hepatic failure after hepatectomy was characterized by the inhibition of hepatic cell cycle priming and progression both induced by ECM remodeling in liver regeneration. Particularly, the overexpression of PAIs was thought to play the major role in the first step of inhibition of ECM remodeling.

A survival case of ABO-incompatible liver transplantation complicated with severe preoperative infection and subsequent overwhelming postsplenectomy infection

A 47-year-old Japanese man was transferred to our hospital because of acute-on-chronic hepatitis B virus infection. On admission, he was suffering from sepsis due to a catheter infection and respiratory failure caused by pulmonary edema and pneumonia, but, as a result of preoperative intensive care, we avoided septic shock. ABO-incompatible liver transplantation (ABO-I-LT) was performed. In accordance with our ABO-I-LT protocol, we administered, rituximab and performed plasma exchange, splenectomy as well as hepatic artery infusion. The patient was discharged 80 days after living donor transplantation (LDLT). However, 136 days after LDLT, he experienced recurrent respiratory failure due to severe pneumonia. At that time, the CD19(+) B-cell count in the peripheral blood flow remained below 1%. We suspected a mixed infection involving Streptococcus pneumonia, Pneumocystis carinii, and fungus. The cause of the complication was overwhelming postsplenectomy infection (OPSI). We started administration of sulfamethoxazole and trimethoprim, ciprofloxacin hydrochloride, and micafungin sodium therapy as well as gamma-globulin. Oxygenation improved gradually; the patient was discharged at 41 days after re-admission. Although this patient survived the OPSI, it was clear that some aspects of the ABO-I-LT protocol should also be altered.

Complete neurological recovery from fulminant hepatic failure with subarachnoid hemorrhage by living donor liver transplantation: a case report

A 29-year-old man was referred to our hospital with fulminant hepatic failure (FHF) and stage III hepatic coma (somnolence and confusion). Living donor liver transplantation (LDLT) was planned for 2 days after admission to our hospital. However, on the day after admission, he lapsed into stage IV hepatic coma: no right reflexes and no response to pain stimuli. Emergency cranial computed tomography revealed a subarachnoid hemorrhage (SAH), but no aneurysm was seen on magnetic resonance angiography. We speculated that the cause of the SAH may have been bleeding of intracranial veins secondary to coagulopathy and overextension of a vein due to brain edema. We considered that only LDLT could improve the coagulopathy and brain edema. The patient recovered consciousness on postoperative day (POD) 2 and was finally discharged from the hospital without neurological deficit on POD 85. This case suggested that SAH is not a prohibiting factor for LDLT in an FHF patient if the cause of the SAH is venous bleeding.

Giant mesenchymal hamartoma of the liver in an adult

We report a case of hepatic mesenchymal hamartoma in an adult; this condition is extremely rare, with only 15 cases having been reported in the English-language literature worldwide. The patient was a 36-year-old woman who was seen at her local hospital for upper abdominal distension. A giant multilocular cystic tumor, which had almost entirely replaced the normal parenchyma of the right lobe of the liver, was diagnosed. She was referred to our hospital, where, with a diagnosis of biliary cystadenoma, the tumor was successfully removed by right hemihepatectomy. After an uneventful postoperative course, the patient was discharged from our hospital. On histological examination, the tumor consisted of numerous cystic lesions without epithelial lining cells; hepatocytes, bile duct, and vascular components, without either lobular structure or atypia, were observed in the pseudocyst wall, leading to a diagnosis of hepatic mesenchymal hamartoma. There have been a few previously reported cases of multifocal hepatic mesenchymal hamartoma reappearing in the remaining liver after hepatectomy, although these cases are considered to be extremely rare. Therefore, periodic follow-up will be necessary for the patient.

Role of nitric oxide synthesized by nitric oxide synthase 2 in liver regeneration

BACKGROUND/AIMS

Nitric oxide synthase 2 (NOS2) is expressed during liver regeneration after a partial hepatectomy (PHx); NOS2 subsequently synthesizes nitric oxide (NO). However, the role of NOS2-synthesized NO in post-PHx liver regeneration remains unclear. We investigated the role of NOS2-synthesized NO in liver regeneration.

METHODS

NOS2 knockout (NOS2-KO) mice and control mice were subjected to PHx. Liver mass recovery and serum alanine aminotransferase (ALT) levels were then evaluated. The expressions of Ki-67 and single-strand DNA were also evaluated in remnant liver specimens. Differences in the gene expression profiles of the two groups of remnant liver specimens were analysed using a microarray and were validated using a reverse transcription-polymerase chain reaction (RT-PCR).

RESULTS

In NOS2-KO mice, liver regeneration was delayed and apoptosis and serum ALT levels were higher than the levels in the control mice. A microarray study and RT-PCR revealed that heat shock protein 70 family (HSP70 family), haeme oxygenase 1 (Hmox1), neuropilin 1 (Nrp1) and epidermal growth factor receptor (EGFR) were downregulated in NOS2-KO mice.

CONCLUSIONS

NOS2-synthesized NO may improve hepatocyte viability through the induction of the HSP70 family and Hmox1 and may sensitize the remnant liver to growth factors through the induction of Nrp1 and EGFR post-PHx.

Usefulness of absorbable sutures in preventing surgical site infection in hepatectomy

We evaluated the usefulness of synthetic absorbable sutures (Vicryl) in preventing surgical site infection (SSI) after hepatectomy. A rat model of 60% partial hepatectomy was used. Bleeding from the cut surface of the liver was controlled by using two suture types: silk and Vicryl. In the Vicryl group, the lesser omentum was slightly adherent to the cut surface of the liver, while in the silk group, the suture remained, and severe adhesions were found. The number of Staphylococcus aureus was significantly larger in the silk group. We compared a group of patients (n = 125) who underwent hepatectomy using silk with one (n = 188) using Vicryl. The respective incidences of SSI and infection on the cut surface of the liver in the Vicryl group (3.2, 1.6%) were significantly lower than in the silk group (11.2, 8.8%). In accordance with the results of multivariate analysis, duration of operation, use of silk sutures and the complication of bile leakage were selected as independent factors. The risk of SSI in the silk group was 3.4 times that in the Vicryl group. The use of synthetic absorbable sutures, instead of silk sutures, in all the procedures of hepatectomy contributed significantly to the prevention of SSI.

Role of three-dimensional imaging in operative planning for hilar cholangiocarcinoma

BACKGROUND

Complex, highly variable, anatomic relationships in the portal hilum complicate the surgical management at hilar cholangiocarcinoma. Preoperative three-dimensional (3D) imaging to stage the tumor and define anatomy may help in planning for curative resection.

METHODS

Between 2003 and 2006, 20 consecutive patients with hilar cholangiocarcinoma underwent preoperative multidetector row computed tomography (MDCT) cholangiography; 3D images of the portal vein, hepatic artery, and bile ducts were created and viewed simultaneously. Longitudinal tumor extension was evaluated by direct cholangiography and 3D cholangiography, and contiguous spread by 2D computed tomography (CT). Of 20 patients, 15 underwent surgical resection. Liver resection was planned based on 3D imaging that allowed visualization of the relationship between the tumor and the umbilical portion of the left portal vein, or the bifurcation of the anterior and posterior branch of the right portal vein. Preoperative and operative findings were compared.

RESULTS

All patients tolerated 3D CT without serious complication. The accuracy rates of longitudinal tumor extension, using the Bismuth-Corlette classification system, were 85% (11/13) and 87% (13/15) with direct cholangiography and 3D cholangiography, respectively. The sensitivity, specificity, and accuracy rates were 100%, 80%, and 87% for portal invasion and 75%, 91%, and 87% for hepatic arterial invasion. The number of bile duct orifices in the cut end of the hilar plate was estimated correctly in 13 of 15 patients. There were no operative deaths. Potentially curative resection was achieved in 14 of 15 patients.

CONCLUSIONS

3D images provide accurate information about the relationship between hilar cholangiocarcinoma and adjacent vessels. This technique is a powerful new tool for improving the proportion of potentially curative resection.

Efficacy of living donor liver transplantation for patients with methylmalonic acidemia

Application of liver transplantation to methylmalonic acidemia (MMAemia) is controversial because MMAemia is caused by a systemic defect of methylmalonyl-CoA mutase. The clinical courses of seven pediatric patients with MMAemia undergoing living donor liver transplantation (LDLT) were reviewed. Serum and urinary methylmalonic acid (MMA) levels were found to be significantly decreased after LDLT, whereas serum and urinary MMA levels did not return to normal in any patient. One patient died of sepsis 44 days after LDLT. The other six patients are currently doing well. All patients had preoperative history of acute metabolic decompensation and/or metabolic stroke. However, no episode of acute metabolic decompensation or metabolic stroke was observed postoperatively in any surviving patients. In the preoperative period, all patients showed lethargy and cognitive deficit, both of which were eradicated after LDLT in all surviving patients. Preoperatively, all patients were subjected to dietary protein intake restriction and tube feeding, and were administered several metabolism-correcting medications. The metabolism-correcting medications being administered remained mostly unchanged after LDLT, whereas protein restriction was liberalized and tube feeding became unnecessary in all surviving patients. In addition, physical and neurodevelopmental growth delay remained in all surviving patients during the observation period, which ranged from 4 to 21 months with a median of 10.5 months.

Perioperative infection control and its effectiveness in hepatectomy patients

BACKGROUND AND AIM

Post-hepatectomy infections require careful attention, because they may deteriorate into liver failure. We retrospectively reviewed such infections in cases without biliary or intestinal reconstruction.

METHODS

This retrospective study involved 535 patients with liver tumors who underwent hepatectomy at the Department of Gastroenterological Surgery of Yokohama City University Hospital between April 1992 and March 2005. After classification into four groups depending on changes in infection countermeasures used during different periods, the treatment outcomes were examined. No such anti-infection measures were taken during the first period; a closed suction drainage system and early enteral nutrition after surgery were introduced between the first and second periods; thorough management of bile leakage and prevention of nosocomial infection were added between the second and third periods; and surgical site infection (SSI) surveillance together with absorbable sutures instead of silk sutures between the third and fourth periods.

RESULTS

The incidence of postoperative infection decreased significantly with additional countermeasures: first period 44.7%; second period 24.1%; third period 15.0%; and fourth period 9.2%. The incidence of both SSI and remote infection were similarly reduced. Postoperative infection risk factors were age, presence of diabetes mellitus, the use of silk sutures and bile leakage, while those for SSI were the use of silk sutures and bile leakage.

CONCLUSION

The incidence of postoperative infection and SSI were significantly reduced by our infection countermeasures, especially by bile leakage management and the use of absorbable sutures.

Histological recurrence of autoimmune liver diseases after living-donor liver transplantation

BACKGROUND

The effects of living donor liver transplantation (LDLT) on the recurrence of autoimmune liver diseases have not been well documented. Genetic similarities may be beneficial to avoid severe rejection but may facilitate the recurrence of autoimmune diseases. Because familial occurrence of autoimmune liver diseases has been documented, there is a possibility that candidates for living-related donors may have the same disease as that of the recipients.

METHOD

Between November 1994 and June 2004, 50 patients with primary biliary cirrhosis (PBC) (16-non-blood-relative donors and 34 blood-relative donors), and 28 patients with primary sclerosing cholangitis (PSC) underwent LDLT in Kyoto University Hospital.

RESULTS

Among 35 patients with PBC who survived more than 1 year, 10 patients (29%) showed recurrent PBC, and nine of 10 patients with recurrent PBC (90%) were associated with blood-relative donors (mean follow-up period, 30 months; range, 2-68). Two recipients had donors with some clinical or histological characteristics of PBC, and their grafts developedrecurrent PBC. Cirrhosis or graft failure was not observed in any patients with recurrent PBC. For PSC patients who survived more than 1 year after LDLT, 13 of 22 (59%) showed PSC-compatible histology and radiological findings (mean follow-up period, 31 months; range, 22-71), and five died or underwent retransplantation. Human leukocyte antigen-DR15 was positively associated with susceptibility to PSC with ulcerative colitis. One donor was revealed to have retroperitoneal fibrosis without evidence of sclerosing cholangitis.

CONCLUSIONS

Blood-relative donors may be associated with susceptibility to recurrent autoimmune diseases. Recurrence of PSC, but not PBC, adversely affected the outcome of LDLT. Caution should be taken as blood-relative donors can be at risk of autoimmune liver diseases.

PAI-1 plays an important role in liver failure after excessive hepatectomy in the rat

BACKGROUND/AIMS

Well-organized turnover of the extracellular matrix is important in liver regeneration, which is regulated by the plasminogen activating system. The aim of this study was to investigate the role of plasminogen activator inhibitor-1 (PAI-1) after excessive hepatectomy and to ascertain whether angiotensin-converting enzyme (ACE) inhibitors, which are PAI-1 inhibitors as well, successfully improve the survival rate of rats that have undergone 95% partial hepatectomy (PHx).

METHODS

Using liver tissues sampled after 90% or 95% PHx, the expression of PAI-1 mRNA was evaluated using reverse transcription polymerase chain reaction. Hepatic PAI-1 protein and urokinase-type plasminogen activator (uPA) levels were determined by enzyme-linked immunosorbent assay. Survival study and cytodynamic analysis by 5-bromo-2'-deoxyuridine staining were performed to evaluate the effects of ACE inhibition.

RESULTS

The levels of PAI-1 mRNA and hepatic PAI-1 protein in the 95% PHx group peaked and were then maintained. By contrast, the uPA level fell relative to the 90% PHx group. Additionally, the hepatic PAI-1 protein level decreased and the survival rate improved in the 95% PHx rats that had undergone ACE inhibition.

CONCLUSIONS

Our experimental results suggest that PAI-1 plays a role in the occurrence of liver failure after excessive hepatectomy via accelerated maturation of pro-uPA and fibrinolytic factors. These are potential molecular therapeutic targets for liver failure after excessive hepatectomy.

Prostaglandin E1 improves survival rate after 95% hepatectomy in rats

BACKGROUND/AIM

Prostaglandin E1 (PGE1) has a wide-ranging effect on cytoprotection. Overproduction of heat shock protein 70 (HSP70) in the liver protects hepatocytes under various pathologic conditions. In this study, we examined the effect of a nontoxic HSP-inducer, PGE1, on acute liver failure after 95% hepatectomy in rats.

METHODS

PGE1 or vehicle was intravenously administered to rats 30 min before and during hepatectomy.

RESULTS

Nine of 30 rats pretreated with PGE1 survived, whereas all 20 rats pretreated with vehicle died within 96 h after operation. During the 24-h postoperative period, PGE1 significantly suppressed the release of alanine aminotransferase and elevation of hyaluronic acid. Histological examination showed that the vacuolized hepatocytes and round hepatocytes with pyknotic nuclei are frequently seen in rats pretreated with vehicle, whereas active regeneration is seen in rats pretreated with PGE1. During the first 24 h after surgery, HSP70 induction was absent in the residual livers of vehicle-treated rats. In contrast, PGE1 stimulated the HSP accumulation within 24 h, and viable hepatocytes contained abundant HSP70 in their nuclei.

CONCLUSION

Our results suggest that PGE1 may prevent acute liver failure after massive hepatectomy, at least in part, by enhancing HSP70 production in the residual liver.