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author:("shirane, Ken")
1.  Cystic Liver Infection after Living Donor Liver Transplantation: A Case Report 
Case Reports in Gastroenterology  2014;8(2):169-174.
There are no reports of cystic liver infection after liver transplantation. Herein, we report a rare case of cystic liver graft infection after living donor liver transplantation (LDLT). The patient was a 24-year-old man with primary sclerosing cholangitis who underwent right lobe graft LDLT. Preoperative abdominal computed tomography (CT) revealed a liver cyst at segment 8 of the donor liver. Biliary reconstruction was performed with hepaticojejunostomy. The postoperative course was uneventful until the patient developed a high fever and abdominal pain 15 months after LDLT. Abdominal contrast CT revealed abscess formation. Percutaneous drainage of the cyst was performed and purulent liquid was drained. The fever gradually subsided after treatment. On follow-up CT, the size of the infected liver cyst was decreased. Clinicians should be aware of the potential for cystic liver infection when using grafts with liver cysts, particularly when biliary reconstruction is performed with hepaticojejunostomy.
doi:10.1159/000363375
PMCID: PMC4049011  PMID: 24932164
Cystic liver infection; Living donor liver transplantation; Percutaneous drainage; Primary sclerosing cholangitis
2.  Spontaneous Massive Necrosis of Hepatocellular Carcinoma with Narrowing and Occlusion of the Arteries and Portal Veins 
Case Reports in Gastroenterology  2014;8(1):148-155.
We herein present the case of a 77-year-old man who had fever and right hypochondriac pain. He visited his doctor and underwent contrast computed tomography (CT), and he was suspected to have a liver abscess. He received an antibiotic treatment and his symptoms soon disappeared, but the tumor did not get smaller and its density on contrast CT image got stronger. He underwent biopsy and moderately differentiated hepatocellular carcinoma (HCC) was found. Extended left hepatic and caudate lobectomy was performed. Histological examination showed moderately differentiated HCC with narrowing and occlusion both in the arteries and portal veins associated with mild chronic inflammation. The mechanisms of spontaneous regression of HCC, such as immunological reactions and tumor hypoxia, have been proposed. In our case, histological examination showed the same findings. However, the mechanism is complex, and therefore further investigations are essential to elucidate it.
doi:10.1159/000362440
PMCID: PMC4036137  PMID: 24926228
Spontaneous necrosis; Hepatocellular carcinoma; Alcoholic liver disease; Hepatectomy
3.  Management of thrombocytopenia due to liver cirrhosis: A review 
Thrombocytopenia is a common complication in liver disease and can adversely affect the treatment of liver cirrhosis, limiting the ability to administer therapy and delaying planned surgical/diagnostic procedures because of an increased risk of bleeding. Multiple factors, including splenic sequestration, reduced activity of the hematopoietic growth factor thrombopoietin, bone marrow suppression by chronic hepatitis C virus infection and anti-cancer agents, and antiviral treatment with interferon-based therapy, can contribute to the development of thrombocytopenia in cirrhotic patients. Of these factors, the major mechanisms for thrombocytopenia in liver cirrhosis are (1) platelet sequestration in the spleen; and (2) decreased production of thrombopoietin in the liver. Several treatment options, including platelet transfusion, interventional partial splenic embolization, and surgical splenectomy, are now available for severe thrombocytopenia in cirrhotic patients. Although thrombopoietin agonists and targeted agents are alternative tools for noninvasively treating thrombocytopenia due to liver cirrhosis, their ability to improve thrombocytopenia in cirrhotic patients is under investigation in clinical trials. In this review, we propose a treatment approach to thrombocytopenia according to our novel concept of splenic volume, and we describe the current management of thrombocytopenia due to liver cirrhosis.
doi:10.3748/wjg.v20.i10.2595
PMCID: PMC3949268  PMID: 24627595
Liver cirrhosis; Thrombocytopenia; Thrombopoietin; Partial splenic embolization; Splenectomy
4.  Laparoscopic liver resection in the semiprone position for tumors in the anterosuperior and posterior segments, using a novel dual-handling technique and bipolar irrigation system 
Surgical Endoscopy  2014;28(8):2484-2492.
Background
Hepatic tumors in the lower edge and lateral segments are commonly treated by laparoscopic liver resection. Tumors in the anterosuperior and posterior segments are often large and locally invasive, and resection is associated with a higher risk of insufficient surgical margins, massive intraoperative bleeding, and breaching of the tumor. Laparoscopic surgery for such tumors often involves major hepatectomy, including resection of a large volume of normal liver tissue. We developed a novel method of laparoscopic resection of tumors in these segments with the patient in the semiprone position, using a dual-handling technique with an intercostal transthoracic port. The aim of this study was to evaluate the safety and usefulness of our technique.
Methods
Of 160 patients who underwent laparoscopic liver resection at our center from June 2008 to May 2013, we retrospectively reviewed those with tumors in the anterosuperior and posterior segments. Patients were placed supine or semilateral during surgery until January 2010 and semiprone from February 2010.
Results
Before the introduction of the semiprone position in February 2010, a total of 7 of 40 patients (17.5 %) with tumors in the anterosuperior and posterior segments underwent laparoscopic liver resection, and after introduction of the semiprone position, 69 of 120 patients (57.5 %) with tumors in the anterosuperior and posterior segments underwent laparoscopic liver resection (P < 0.001). There were no conversions to open surgery, reoperations, or deaths. The semiprone group had a significantly higher proportion of patients who underwent partial resection or segmentectomy of S7 or S8, lower intraoperative blood loss, and shorter hospital stay than the supine group (all P < 0.05). Postoperative complication rates were similar between groups.
Conclusions
Laparoscopic liver resection in the semiprone position is safe and increases the number of patients who can be treated by laparoscopic surgery without increasing the frequency of major hepatectomy.
Electronic supplementary material
The online version of this article (doi:10.1007/s00464-014-3469-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s00464-014-3469-y
PMCID: PMC4077249  PMID: 24622763
Pure laparoscopic hepatectomy; Semiprone position; Anterosuperior and posterior segments; Dual-handling technique; Intercostal transthoracic port
5.  Portal vein thrombosis in liver cirrhosis 
World Journal of Hepatology  2014;6(2):64-71.
Portal vein thrombosis (PVT) is considered to be a frequent complication of liver cirrhosis. However, unlike PVT in patients without cirrhosis, very few data are available on the natural history and management of PVT in cirrhosis, despite its association with potentially life-threatening conditions, such as gastroesophageal bleeding and acute intestinal ischemia. Moreover, no consensus regarding PVT in cirrhosis exists. Suggested causes of PVT in cirrhosis include reduced portal blood flow velocity, multiple congenital or acquired thrombophilic factors, inherited or acquired conditions, and derangement of liver architecture. However, the understanding of PVT in cirrhosis is incomplete. In addition, information on the management of PVT in cirrhosis is inadequate. The aims of this review are to: (1) assemble data on the physiopathological mechanism, clinical findings, diagnosis and management of PVT in cirrhosis; (2) describe the principal factors most frequently involved in PVT development; and (3) summarize the recent knowledge concerning diagnostic and therapeutic procedures.
doi:10.4254/wjh.v6.i2.64
PMCID: PMC3934638  PMID: 24575165
Portal vein thrombosis; Liver cirrhosis; Thrombophilic factors; Anticoagulation; Splenectomy
6.  New molecular staging with G-factor supplements TNM classification in gastric cancer: a multicenter collaborative research by the Japan Society for Gastroenterological Carcinogenesis G-Project committee 
Gastric Cancer  2014;18(1):119-128.
Background
The G-Project committee was erected by the Japan Society for Gastroenterological Carcinogenesis with an aim of establishing a new classification scheme based on molecular biological characteristics that would supplement the conventional TNM classification to better predict outcome.
Methods
In a literature search involving 822 articles on gastric cancer, eight molecules including p53, vascular endothelial growth factor (VEGF)-A, VEGF-C, matrix metalloproteinase-7 (MMP-7), human epidermal growth factor receptor 2, Regenerating islet-derived family, member 4, olfactomedin-4 and Claudin-18 were selected as candidates to be included in the new molecular classification scheme named G-factor. A total of 210 cases of gastric cancer who underwent curative R0 resection were registered from four independent facilities. Immunohistochemical staining for the aforementioned molecules was performed for the surgically resected specimens of the 210 cases to investigate the correlation between clinicopathological factors and expression of each molecule.
Results
No significant correlation was observed between the immunostaining expression of any of the eight factors and postoperative recurrence. However, the expressions of p53 and MMP-7 were significantly correlated with overall survival (OS). When 210 gastric cancer patients were divided into three groups based on the expression of p53 and MMP-7 (G0 group: negative for both p53 and MMP-7, n = 69, G1 group: positive for either p53 or MMP-7, n = 97, G2 group: positive for both of the molecules, n = 44), G2 group demonstrated significantly higher recurrence rate (59 %) compared to 38 % in G0 (p = 0.047). The multivariate regression analysis revealed that G2 group was independently associated with a shorter disease-free survival (DFS) (hazard ratio 1.904, 95 % CI 1.098–3.303; p = 0.022), although the association with OS was not significant. Stage II patients among the G2 group had significantly inferior prognosis both in terms of OS and DFS when compared with those among the G0/G1 group, with survival curves similar to those of Stage III cases.
Conclusions
G-factor based on the expression of p53 and MMP-7 was found to be a promising factor to predict outcome of Stage II/III gastric cancer, and possibly to help select the treatment for Stage II cancer, thus supplementing the conventional TNM system.
doi:10.1007/s10120-014-0338-2
PMCID: PMC4257995  PMID: 24488015
Gastric cancer; G-factor; Molecular staging; TNM classification
7.  New molecular staging with G-factors (VEGF-C and Reg IV) by supplementing TNM classification in colorectal cancers 
Oncology Reports  2013;30(6):2609-2616.
Staging classification of colorectal cancers is performed by the UICC/TNM classification system, which is the global gold standard. However, we often experience in clinical practice that there are considerable differences in prognoses between patients who have the same classification particularly in stage II and III cancers. The aim of this study was to propose a new TNM-G classification to predict prognosis and recurrence by supplementing the conventional TNM classification. A total of 220 cases of colorectal cancer, including 77 at stage II and 143 at stage III, were registered from four independent facilities. Immunohistochemical staining for 7 molecules, such as p53, vascular endothelial growth factor (VEGF)-A, VEGF-C, regenerating islet-derived family, member 4 (Reg IV), olfactomedin 4, Claudin-18 and matrix metalloproteinase-7 (MMP-7), was performed to investigate the correlation between clinicopathological factors and expression of each molecule. Based on the results, no significant correlation was observed between the immunostaining expression of these 7 factors and recurrence in total colorectal cancer. Recurrence in stage II (77 cases) was significantly higher in cases positive for Reg IV expression (P=0.042). On analysis of overall survival (OS) and disease-free survival (DFS), VEGF-C and Reg IV expression had a correlation with poor prognosis, therefore, these factors were selected and applied to G-factor classifications so that cases negative for both could be classified as G0, cases positive for either of the factors could be classified as G1, and cases positive for both factors could be classified as G2. While no significant correlation was observed in the recurrence rates between G0 and G2, OS and DFS in stage II cases were significantly poorer for G2 cases in comparison with G0 or G1 cases. The survival curves of OS and DFS in stage II G2 were similar to that of stage III cases. According to these results, prognosis of VEGF-C/Reg IV both positive G2 cases in stage II colorectal cancer was found to be almost equal to the poor survival in stage III cases, and the advancement of one stage up migration based on G-factors may be supposed to be highly feasible for clinical application. In conclusion, the combination of VEGF-C and Reg IV may be a promising factor for clinical staging to supplement the classical TNM classification system, and it may suggest a good indication of adjuvant chemotherapy for G2 cases in stage II colorectal cancers.
doi:10.3892/or.2013.2787
PMCID: PMC3839952  PMID: 24101199
colorectal cancer; G-factor; TNM classification; molecular stage; VEGF-C; Reg IV
8.  A safe combined nephrectomy and right lobectomy using the liver hanging maneuver for huge renal cell carcinoma directly invading the right lobe of the liver: report of a case 
Surgery Today  2013;44(9):1778-1782.
We herein discuss a patient who underwent simultaneous combined right nephrectomy and right lobectomy of the liver. A 64-year-old male was diagnosed with a huge right renal cell carcinoma (RCC), 13 cm in diameter, which was invading directly into the right hepatic lobe. This type of RCC has been rarely reported, and an anterior approach using the liver hanging maneuver was extremely useful during hepatic parenchymal dissection. The liver parenchymal dissection was performed prior to mobilization of the liver, because the mobilization of the right lobe of the liver was impossible. During the hepatic parenchymal resection, the liver was suspended with the tape and transected, and thereafter, retroperitoneal dissection, nephrectomy and right lobectomy of the liver were completed. The patient was discharged from the hospital on the 12th postoperative day with an uneventful clinical course. The anterior approach using the liver hanging maneuver during hepatic parenchymal resection can be safe and feasible for huge RCC invading the right hepatic lobe.
doi:10.1007/s00595-013-0693-3
PMCID: PMC4138431  PMID: 24048764
9.  Non-cirrhotic portal-systemic encephalopathy caused by enlargement of a splenorenal shunt after pancreaticoduodenectomy for locally advanced duodenal cancer: report of a case 
Surgery Today  2013;44(8):1573-1576.
We report a case of portal-systemic encephalopathy occurring secondary to a splenorenal shunt, 2 years after a pancreaticoduodenectomy for locally advanced duodenal carcinoma. A 55-year-old woman was brought to our hospital with a decreased level of consciousness. Laboratory testing revealed an elevated serum ammonia level (221 μg/dl) and normal liver function. Retrospective review of a series of contrast-enhanced computed tomography scans of the abdomen identified a splenorenal shunt, which had gradually enlarged over the past 2 years (Fig. 1). The decreased level of consciousness was thought to be due to portal-systemic encephalopathy secondary to the splenorenal shunt. We performed balloon-occluded retrograde transvenous obliteration to occlude the splenorenal shunt, following which her serum ammonia level returned to normal (28 μg/dl) and an alert level of consciousness was maintained.Fig. 1Review of abdominal computed tomography scans. a Preoperatively, b 6 months postoperatively, c 1 year postoperatively, d 2 years and 2 months postoperatively. The shunt vessel gradually enlarged after pancreaticoduodenectomy (circle)
doi:10.1007/s00595-013-0679-1
PMCID: PMC4097198  PMID: 23982193
Encephalopathy; Splenorenal shunt; Duodenal cancer; Pancreaticoduodenectomy; Balloon-occluded retrograde transvenous obliteration
10.  Feasible Isolated Liver Transplantation for a Cirrhotic Patient on Chronic Hemodialysis 
Case Reports in Gastroenterology  2013;7(2):299-303.
End-stage liver and kidney disease (ELKD) is an indication for deceased donor simultaneous liver-kidney transplantation. Although a few cases of living donor liver-kidney transplantation have been reported, the invasiveness remains to be discussed. Living donor liver transplantation (LDLT) is an alternative choice for ELKD, but has never been reported. Here, we report a case of successful LDLT for a patient with ELKD on hemodialysis. The patient was a 63-year-old male and had decompensated hepatitis C cirrhosis with seronegativity for hepatitis C virus. He had non-diabetic end-stage renal failure and had been on hemodialysis for 3 years. He was in good general condition except for hepatic and renal failure. The living donor was his 58-year-old healthy wife. A right lobe graft was transplanted to the recipient under continuous hemodiafiltration (CHDF) and extracorporeal veno-venous bypass. CHDF was continued until postoperative day 4, at which point CHDF was converted to hemodialysis. His posttransplant course was good and he was discharged on postoperative day 36. To the best of our knowledge, this is the first report of LDLT for a patient on chronic hemodialysis. Therefore, being on hemodialysis is not a contraindication for LDLT. LDLT is feasible for a patient with ELKD on hemodialysis.
doi:10.1159/000354140
PMCID: PMC3728599  PMID: 23904841
Living donor liver transplantation; Hepatitis C; Hemodialysis
11.  Composite adeno-endocrine carcinoma of the gallbladder with long-term survival 
INTRODUCTION
Primary endocrine cell tumors in the gallbladder are uncommon, and the coexistence of an endocrine cell tumor and adenocarcinoma, squamous cell carcinoma, and sarcomatoid components is extremely rare.
PRESENTATION OF CASE
A rare case of adeno-endocrine cell carcinoma of the gallbladder in an 81-year-old woman is reported. Abdominal ultrasonography (US) revealed a hypo-echoic, solid tumor, 2.0 cm × 1.8 cm in size, at the fundus of the gallbladder. On computed tomography (CT), the tumor was well-enhanced, well-demarcated, and homogeneous. The tumor, which was papillary, protruded into the gallbladder with no direct invasion to the liver. The tumor was diagnosed as gallbladder carcinoma; its depth appeared not to pass the subserosa layer. A cholecystectomy and hepatic bed resection with regional lymph node dissection were performed. Histologically, the tumor consisted of several components, including well to poorly differentiated papillary and tubular adenocarcinoma with squamous and sarcomatoid differentiations, and endocrine cell carcinoma. Histochemical studies of these tumor cells were positive for chromogranin A, synaptophysin, and cluster of differentiation 56 (CD56). The lymph node consisted of metastatic adeno-endocrine carcinoma. The patient survived and has remained disease-free for 4 years without adjuvant chemotherapy.
DISCUSSION
Adeno-endocrine cell carcinoma of the gallbladder generally has a poor prognosis.
CONCLUSION
The present case suggests that adeno-endocrine cell carcinoma with various components may be derived from a common precursor cell. This observation would require further investigation.
doi:10.1016/j.ijscr.2013.02.013
PMCID: PMC3731699  PMID: 23562903
Composite tumor; Gallbladder; Adeno-endocrine cell carcinoma
12.  Effect of laparoscopic splenectomy in patients with Hepatitis C and cirrhosis carrying IL28B minor genotype 
BMC Gastroenterology  2012;12:158.
Background
IL28B and ITPA genetic variants are associated with the outcome of pegylated-interferon and ribavirin (PEG-IFN/RBV) therapy. However, the significance of these genetic variants in cirrhotic patients following splenectomy has not been determined.
Methods
Thirty-seven patients with HCV-induced cirrhosis who underwent laparoscopic splenectomy (Spx group) and 90 who did not (non-Spx group) were genotyped for IL28B and ITPA. The outcome or adverse effects were compared in each group. Interferon-stimulated gene 15 (ISG15) and protein kinase R expression in the spleen was measured using total RNA extracted from exenterate spleen.
Results
Sustained virological response (SVR) rate was higher in patients carrying IL28B major genotype following splenectomy (50% vs 27.3%) and in patients carrying minor genotype in the Spx group compared to non-Spx group (27.3% vs 3.6%, P < 0.05). Pretreatment splenic ISG expression was higher in patients carrying IL28B major. There was no difference in progression of anemia or thrombocytopenia between patients carrying each ITPA genotype in the Spx group. Although splenectomy did not increase hemoglobin (Hb) level, Hb decline tended to be greater in the non-Spx group. In contrast, splenectomy significantly increased platelet count (61.1 × 103/μl vs 168.7 × 103/μl, P < 0.01), which was maintained during the course of PEG-IFN/RBV therapy.
Conclusions
IL28B genetic variants correlated with response to PEG-IFN/RBV following splenectomy. Splenectomy improved SVR rate among patients carrying IL28B minor genotype and protected against anemia and thrombocytopenia during the course of PEG-IFN/RBV therapy regardless of ITPA genotype.
doi:10.1186/1471-230X-12-158
PMCID: PMC3503804  PMID: 23145809
IL28B; ITPA; Splenectomy; Liver cirrhosis
13.  Neither MICA Nor DEPDC5 Genetic Polymorphisms Correlate with Hepatocellular Carcinoma Recurrence following Hepatectomy 
HPB Surgery  2012;2012:185496.
Purpose. Genetic polymorphisms of MICA and DEPDC5 have been reported to correlate with progression to hepatocellular carcinoma (HCC) in chronic hepatitis C patients. However, correlation of these genetic variants with HCC recurrence following hepatectomy has not yet been clarified. Methods. Ninety-six consecutive HCC patients who underwent hepatectomy, including 64 patients who were hepatitis C virus (HCV) positive, were genotyped for MICA (rs2596542) and DEPDC5 (rs1012068). Recurrence-free survival rates (RFS) were compared for each genotype. Results. Five-year HCC recurrence-free survival (RFS) rates following hepatectomy were 20.7% in MICA GG allele carriers, 38.7% in GA, and 20.8% in AA, respectively (P = 0.72). The five-year RFS rate was 23.8% in DEPDC5 TT allele carriers and 31.8% in TG/GG, respectively (P = 0.47). The survival rates in all (including HCV-negative) patients were also similar among each MICA and DEPDC5 genotype following hepatectomy. Among HCV-positive patients carrying the DEPDC5 TG/GG allele, low fibrosis stage (F0-2) occurred more often compared with TT carriers (P < 0.05). Conclusions. Neither MICA nor DEPDC5 genetic polymorphism correlates with HCC recurrence following hepatectomy. DEPDC5 minor genotype data suggest a high susceptibility for HCC development in livers, even those with low fibrosis stages.
doi:10.1155/2012/185496
PMCID: PMC3485991  PMID: 23132957
14.  Pure laparoscopic hepatectomy in semiprone position for right hepatic major resection 
Background
Pure laparoscopic liver resection is technically difficult for tumors located in the dorsal anterior and posterior sectors. We have developed a maneuver to perform pure laparoscopic hepatectomy in the semiprone position which was developed for resecting tumors located in these areas.
Methods
The medical records have been reviewed retrospectively in 30 patients who underwent laparoscopic liver resection in the semiprone position for carcinoma in the dorsal anterior or posterior sectors of the right liver between 2008 and 2011.
Results
Seventeen liver tumors were primary liver tumors and 13 were colorectal metastases. Of the 30 patients, 11 (36.6 %) underwent major hepatectomy [right hemihepatectomy in 7 (23.3 %) and posterior sectionectomy in 4 (13.3 %)]. Anatomical minor resection, such as S6 or S7 segmentectomy, was performed in five patients (16.6 %). Five patients with liver metastasis underwent a simultaneous laparoscopic resection. There was no mortality, reoperation, or conversion to open procedures. There were no hepatectomy-related complications such as postoperative bleeding, bile leakage, or liver failure.
Conclusions
Pure laparoscopic hepatectomy in the semiprone position for tumors present in the dorsal anterior and posterior sectors is feasible and safe. This method expands the indications for laparoscopic liver resection for tumors.
Electronic supplementary material
The online version of this article (doi:10.1007/s00534-012-0558-y) contains supplementary material, which is available to authorized users.
doi:10.1007/s00534-012-0558-y
PMCID: PMC3572367  PMID: 23053355
Pure laparoscopic hepatectomy; Semiprone position; Anatomical liver resection; Rouviere’s sulcus
15.  The Interaction Between Toll Like Receptors and Natural Killer Cells in the Destruction of Bile Ducts in Primary Biliary Cirrhosis 
Hepatology (Baltimore, Md.)  2011;53(4):1270-1281.
Primary biliary cirrhosis (PBC) is characterized by chronic non-suppurative destructive cholangitis (CNSDC) associated with destruction of small bile ducts. Although there have been significant advancements in the dissection of the adaptive immune response against the mitochondrial autoantigens, there is increasing data that suggests a contribution of innate immune mechanisms in inducing chronic biliary pathology. We have taken advantage of our ability to isolate subpopulations of liver mononuclear cells (LMC) and examined herein the role of toll-like receptors (TLR), their ligands and natural killer (NK) cells in modulating cytotoxic activity against biliary epithelial cells (BECs). In particular, we demonstrate that toll-like receptor 4 ligand (TLR4-L) stimulated NK cells destroy autologous BECs in the presence of interferon (IFN)-α synthesized by TLR 3 ligand (TLR3-L) stimulated monocytes (Mo). Indeed, IFN-α production by hepatic Mo is significantly increased in patients with PBC compared to disease controls. There were also marked increases in the cytotoxic activity of hepatic NK cells from PBC patients compared to NK cells from controls but only when the NK cells were prepared following ligation of both TLR3-L and TLR4-L stimulated LMC. These functional data are supported by the immunohistochemical observation of an increased presence of CD56 positive NK cells scattered around destroyed small bile ducts more frequently in liver tissues from PBC patients than controls. In conclusion, these data highlight critical differences in the varied roles of Mo and NK cells following TLR3-L and TLR4-L stimulation.
doi:10.1002/hep.24194
PMCID: PMC3077894  PMID: 21400555
natural killer cells; monocytes; biliary epithelial cells; toll-like receptors; IFN-α; primary biliary cirrhosis
16.  Intrahepatic bile duct recurrence of hepatocellular carcinoma without a detectable liver tumor 
INTRODUCTION
Invasion of the portal and hepatic veins by hepatocellular carcinoma (HCC) is common, but macroscopic bile duct invasion is rare. Once a tumor thrombus completely obstructs the main bile duct, it causes obstructive jaundice. This type of HCC, known as icteric-type HCC (IHCC), has a poor prognosis.
PRESENTATION OF CASE
A 72-year-old woman had been treated for chronic hepatitis C since 1997. In 2002, percutaneous ethanol injection therapy was performed for HCC in segment 8. HCC recurrence occurred in 2004, and she underwent transarterial embolization (TAE) and radiofrequency ablation (RFA). In 2006, an S8 segmentectomy was performed for re-recurrence of HCC. Three years after surgery, computed tomography (CT) revealed a tumor occupying the right anterior intrahepatic bile duct and extending into its right main branch. With a preoperative diagnosis of HCC recurrence in the bile duct, we performed a right hepatectomy and thrombectomy. Histological examination showed moderately to poorly differentiated HCC. No tumor tissue other than the intrahepatic bile duct tumor was detected in the resected liver specimen.
DISCUSSION
HCC with biliary tumor thrombus is associated with a poor prognosis. In general, IHCC is difficult to diagnose and treat in the early stages. A characteristic radiological finding for this type of IHCC is the hypervascularity of the tumor thrombus.
CONCLUSION
To the best of our knowledge, this is a rare case of IHCC recurrence as a tumor thrombus without recurrence in the resected liver specimen.
doi:10.1016/j.ijscr.2012.03.017
PMCID: PMC3356541  PMID: 22516418
Hepatocellular carcinoma (HCC); Intraductal tumor; Tumor thrombus
17.  Additional Resection of the Pancreas Body Prevents Postoperative Pancreas Fistula in Patients with Portal Annular Pancreas Who Undergo Pancreaticoduodenectomy 
Case Reports in Gastroenterology  2012;6(1):131-134.
Portal annular pancreas (PAP) is a rare variant in which the uncinate process of the pancreas extends to the dorsal surface of the pancreas body and surrounds the portal vein or superior mesenteric vein. Upon pancreaticoduodenectomy (PD), when the pancreas is cut at the neck, two cut surfaces are created. Thus, the cut surface of the pancreas becomes larger than usual and the dorsal cut surface is behind the portal vein, therefore pancreatic fistula after PD has been reported frequently. We planned subtotal stomach-preserving PD in a 45-year-old woman with underlying insulinoma of the pancreas head. When the pancreas head was dissected, the uncinate process was extended and fused to the dorsal surface of the pancreas body. Additional resection of the pancreas body 1 cm distal to the pancreas tail to the left side of the original resection line was performed. The new cut surface became one and pancreaticojejunostomy was performed as usual. No postoperative complications such as pancreatic fistula occurred. Additional resection of the pancreas body may be a standardized procedure in patients with PAP in cases of pancreas cut surface reconstruction.
doi:10.1159/000335210
PMCID: PMC3335356  PMID: 22532811
Portal annular pancreas; Pancreaticoduodenectomy; Pancreas fistula
18.  Resection of metastatic liver cancer in a patient with a left-sided gallbladder and intrahepatic portal vein and bile duct anomalies: A case report 
INTRODUCTION
The presence of left-sided gallbladder is closely associated with multiple combined anomalies of the portal vein, hepatic vein, hepatic artery, and bile duct. This requires special attention for preoperative evaluation for the purpose of preventing postoperative complications.
PRESENTATION OF CASE
A 70-year-old woman with metastatic liver cancer and intrahepatic portal vein, biliary system and hepatic artery anomalies with left-sided gallbladder is reported. On computed tomography (CT), a solitary low density mass occupied from the right anterior to the posterior segment of the liver. The gallbladder bed was on the left of the hepatic fissure. On drip-infusion-cholangiography (DIC) CT three-dimensional (3D) reconstruction, the left medial bile duct arose from the right umbilical portion after arising from the left lateral bile duct. Following a right hepatectomy and lymph node dissection of the hepatoduodenal ligament, hepaticojejunostomy was conducted separately to the left medial and left lateral bile duct.
DISCUSSION
The left-sided gallbladder accompanies with several anomalies of hepatic vascular and bile duct anomalies in a frequent manner. A safe hepatectomy needs accurate operative plans to ascertain the range of hepatectomy, because it often has the diversity of a combined anomaly.
CONCLUSION
Preoperative DIC-CT 3D reconstruction was extremely useful because it provided an important information that could not be obtained with 2D-DIC-CT. 3D imaging has the ability to demonstrate complex anatomical relationships, this devise is a effective new tool for making appropriate preoperative strategy.
doi:10.1016/j.ijscr.2012.01.003
PMCID: PMC3312050  PMID: 22365920
Intrahepatic portal and biliary system anomalies; Right round ligament; Left-sided gallbladder
19.  Role of UCP2 Expression after Hepatic Warm Ischemia-Reperfusion in the Rat 
Gut and Liver  2011;5(4):486-492.
Background/Aims
The role of uncoupling protein-2 (UCP2) in the liver is currently unclear. Emerging evidence suggests a relationship between UCP2 and oxidative stress. In the present study, we tested the hypothesis that UCP2 expression in the liver might change during warm ischemia-reperfusion (I/R) according to oxidative stress.
Methods
Wistar rats were subjected to 40 (short ischemia) or 90 (long ischemia) minutes of partial lobar ischemia followed by 4 hours of reperfusion. UCP2 expression in the ischemic and nonischemic lobes was assessed using reverse transcription-polymerase chain reaction and immunohistochemistry. Malondialdehyde concentrations in the liver tissue were also compared.
Results
Malondialdehyde concentrations in the ischemic lobes were significantly higher in the long ischemia group. In the ischemic lobes of the short ischemia group, UCP2 protein expression was induced in hepatocytes, which did not express the protein prior to treatment, and the expression levels were higher than in the long ischemia group. The intralobular distribution of UCP2 seemed to correlate inversely with that of the necrotic area. UCP2 expression was observed, even in nonischemic lobes with similar intralobular heterogeneity.
Conclusions
UCP2 was induced in hepatocytes after warm I/R. Although the primitive role of UCP2 expression may be cytoprotective in nature, its actual protective effect in hepatic I/R may be minimal
doi:10.5009/gnl.2011.5.4.486
PMCID: PMC3240793  PMID: 22195248
Oxidative stress; Ischemia-reperfusion; Uncoupling protein; Liver; Surgery
20.  Successful Treatment for Hepatic Encephalopathy Aggravated by Portal Vein Thrombosis with Balloon-Occluded Retrograde Transvenous Obliteration 
Case Reports in Gastroenterology  2011;5(2):366-371.
This report presents the case of a 78-year-old female with hepatic encephalopathy due to an inferior mesenteric venous-inferior vena cava shunt. She developed hepatocellular carcinoma affected by hepatitis C virus-related cirrhosis and underwent posterior sectionectomy. Portal vein thrombosis developed and the portal trunk was narrowed after hepatectomy. Portal vein thrombosis resulted in high portal pressure and increased blood flow in an inferior mesenteric venous-inferior vena cava shunt, and hepatic encephalopathy with hyperammonemia was aggravated. The hepatic encephalopathy aggravated by portal vein thrombosis was successfully treated by balloon-occluded retrograde transvenous obliteration via a right transjugular venous approach without the development of other collateral vessels.
doi:10.1159/000330287
PMCID: PMC3134060  PMID: 21769289
Hepatic encephalopathy; Portal vein thrombosis; Balloon-occluded retrograde transvenous obliteration
21.  Prospective randomized controlled trial investigating the type of sutures used during hepatectomy 
AIM: To determine whether absorbable sutures or non-absorbable sutures are better in preventing surgical site infection (SSI), in this paper we discuss the results of a randomized clinical trial which examined the type of sutures used during hepatectomy.
METHODS: All hepatic resections performed from January 2007 to November 2008 at the Department of Surgery at Iizuka Hospital in Japan were included in this study. There were 125 patients randomly assigned to an absorbable sutures (Vicryl) group or non-absorbable sutures (Silk) group.
RESULTS: SSI was observed in 13.6% (17/125) patients participating in this study, 11.3% in the Vicryl group and 15.8% in the Silk group. Incisional SSI including superficial and deep SSI, was observed in 8% of the Vicryl group and 9.5% of the Silk group. Organ/space SSI was observed in 3.2% of the Vicryl group and 6.0% of the Silk group. There were no significant differences, but among the patients with SSI, the period for recovery was significantly shorter for the Vicryl group compared to the Silk group.
CONCLUSION: The incidence of SSI in patients receiving absorbable sutures and silk sutures is not significantly different in this randomized controlled study; however, the period for recovery in patients with SSI was significantly shorter for absorbable sutures.
doi:10.3748/wjg.v17.i18.2338
PMCID: PMC3098402  PMID: 21633600
Hepatectomy; Absorbable suture; Surgical site infection
22.  The prevalence of circumportal pancreas as shown by multidetector-row computed tomography 
Insights into Imaging  2011;2(4):409-414.
Objective
To evaluate the prevalence of circumportal pancreas (CP) and any coexisting anomaly. In addition, three cases of surgically confirmed CP are presented.
Methods
The study group consisted of 317 consecutive potential liver transplant donor candidates who had undergone thin-section MDCT studies for the evaluation of vascular anatomy. MDCT images were retrospectively reviewed to assess the presence or absence of CP. If CP was present, the transverse diameter of the aberrant pancreatic tissue was measured on axial images, and the course of the main pancreatic duct (MPD) was classified into ante-portal (normal) or retro-portal. In addition, the prevalence of variant hepatic arterial anatomy was compared between cases with and without CP.
Results
Eight of 317 liver transplant donor candidates (2.5%) were found to have CP at CT. The transverse diameter of the aberrant pancreatic tissue ranged from 5 to 18 mm (mean ± SD: 10 ± 4 mm). One of eight (12.5%) showed the MPD to be retro-portal. A variant hepatic artery was noted in two of the of eight (25%) patients, which was similar to the finding for those without CP [72 out of 309 (23%)].
Conclusion
The prevalence of circumportal pancreas was 2.5%.
doi:10.1007/s13244-011-0092-5
PMCID: PMC3259370  PMID: 22347962
Pancreas; Anatomy; Anomaly; Pancreatic surgery; MDCT
23.  The prevalence of circumportal pancreas as shown by multidetector-row computed tomography 
Insights into Imaging  2011;2(4):409-414.
Objective
To evaluate the prevalence of circumportal pancreas (CP) and any coexisting anomaly. In addition, three cases of surgically confirmed CP are presented.
Methods
The study group consisted of 317 consecutive potential liver transplant donor candidates who had undergone thin-section MDCT studies for the evaluation of vascular anatomy. MDCT images were retrospectively reviewed to assess the presence or absence of CP. If CP was present, the transverse diameter of the aberrant pancreatic tissue was measured on axial images, and the course of the main pancreatic duct (MPD) was classified into ante-portal (normal) or retro-portal. In addition, the prevalence of variant hepatic arterial anatomy was compared between cases with and without CP.
Results
Eight of 317 liver transplant donor candidates (2.5%) were found to have CP at CT. The transverse diameter of the aberrant pancreatic tissue ranged from 5 to 18 mm (mean ± SD: 10 ± 4 mm). One of eight (12.5%) showed the MPD to be retro-portal. A variant hepatic artery was noted in two of the of eight (25%) patients, which was similar to the finding for those without CP [72 out of 309 (23%)].
Conclusion
The prevalence of circumportal pancreas was 2.5%.
doi:10.1007/s13244-011-0092-5
PMCID: PMC3259370  PMID: 22347962
Pancreas; Anatomy; Anomaly; Pancreatic surgery; MDCT
24.  Solitary Asymptomatic Thyroid Metastasis from Hepatocellular Carcinoma Detected by FDG-PET/CT 
Case Reports in Gastroenterology  2010;4(2):279-285.
Thyroid metastases from hepatocellular carcinoma (HCC) seldom occur and are often difficult to diagnose because of their asymptomatic clinical course. We evaluated a very rare case of solitary thyroid metastasis from HCC that showed high uptake of fluorine-18 fluorodeoxyglucose (FDG), when imaged using fluorine-18 fluorodeoxyglucose positron emission tomography/computed tomography (FDG-PET/CT). The patient was a 74-year-old man and presented with a remarkably elevated des-gamma-carboxy prothrombin level of 1,157 mAU/ml 22 months after hepatic lobectomy. FDG-PET/CT imaging revealed a hypodense tumor with high FDG uptake, with a maximum standardized uptake value of 5.2 in the thyroid left lobe. Solitary thyroid metastasis from HCC was suspected and subsequent fine needle aspiration did indeed reveal HCC. The patient received left thyroidectomy with left regional lymph node dissection. Two months after left thyroidectomy, contrast-enhanced computed tomography showed local recurrence, and the patient received ongoing radiotherapy treatment. To our knowledge, the present study is the first to demonstrate the feasibility of FDG-PET/CT in the diagnosis and management of clinically diagnosed, asymptomatic, solitary thyroid metastasis from HCC.
doi:10.1159/000318858
PMCID: PMC3047758  PMID: 21383951
Thyroid metastasis; Hepatocellular carcinoma; FDG-PET/CT
25.  Antineoplastic Effects of Gamma Linolenic Acid on Hepatocellular Carcinoma Cell Lines 
The aim of this study was to investigate the effect and the mechanism of gamma linolenic acid (GLA) treatment on human hepatocellular (HCC) cell lines. The human HCC cell line HuH7 was exposed to GLA. Cell proliferation and reactive oxygen species (ROS) generation including lipid peroxidation and apoptosis were compared. We then used a cDNA microarray analysis to investigate the molecular changes induced by GLA. GLA treatment significantly reduced cell proliferation, generated ROS, and induced apoptosis. After 24 h exposure of Huh7 cells to GLA, we identified several genes encoding the antioxidant proteins to be upregulated: heme oxygenase-1 (HO-1), aldo-keto reductase 1 family C1 (AKR1C1), C4 (AKR1C4), and thioredoxin (Trx). The HO-1 protein levels were overexpressed in Huh7 cells after GLA exposure using a Western blot analysis. Furthermore, chromium mesoporphyrin (CrMP), an inhibitor of HO activity, significantly potentiated GLA cytotoxicity. GLA treatment has induced cell growth inhibition, ROS generation including lipid peroxidation, and HO-1 production for antioxidant protection against oxidative stress caused by GLA in Huh7 cells. GLA treatment should be considered as a therapeutic modality in patients with advanced HCC.
doi:10.3164/jcbn.10-24
PMCID: PMC2901768  PMID: 20664735
gamma linolenic acid; hepatocellular carcinoma; oxidant stress; heme oxygenase-1

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