High dorsal resection for hepatocellular carcinoma: surgical plane and outcomes.

High dorsal resection (HDR) of the liver is a systematic resection technique for hepatocellular carcinoma (HCC) arising in the caudate lobe. HDR is rarely performed, as the procedure requires a high level of operative skill, knowledge of liver anatomy and is performed in patients with limited hepatic function. Between 2002 and 2012, we performed HDR on 9 patients. The median operation time was 534 min (range, 349-903 min), and the median blood loss volume was 430 mL (range, 94-4,530 mL). The severe morbidity rate was 11.1%, but there was no operative mortality, and the median hospitalization was 13 days (range, 8-93 days). The overall survival was 49.7 months (range, 3.1-89.0 months). Despite the hard-to-approach anatomic location, HDR can be carried out safely with good survival compared to other segments.

Algorithm for Resecting Hepatocellular Carcinoma in the Caudate Lobe.

OBJECTIVE: To propose an algorithm for resecting hepatocellular carcinoma (HCC) in the caudate lobe. BACKGROUND: Owing to a deep location, resection of HCC originating in the caudate lobe is challenging, but a plausible guideline enabling safe, curable resection remains unknown. METHODS: We developed an algorithm based on sublocation or size of the tumor and liver function to guide the optimal procedure for resecting HCC in the caudate lobe, consisting of 3 portions (Spiegel, process, and caval). Partial resection was prioritized to remove Spiegel or process HCC, while total resection was aimed to remove caval HCC depending on liver function. RESULTS: According to the algorithm, we performed total (n = 43) or partial (n = 158) resections of the caudate lobe for HCC in 174 of 201 patients (compliance rate, 86.6%), with a median blood loss of 400 (10-4530) mL. Postoperative morbidity (Clavien grade ≥III b) and mortality rates were 3.0% and 0%, respectively. After a median follow-up of 2.6 years (range, 0.5-14.3), the 5-year overall and recurrence-free survival rates were 57.3% and 15.3%, respectively. Total and partial resection showed no significant difference in overall survival (71.2% vs 54.0% at 5 yr; P = 0.213), but a significant factor in survival was surgical margin (58.0% vs 45.6%, P = 0.034). The major determinant for survival was vascular invasion (hazard ratio 1.7, 95% CI 1.0-3.1, P = 0.026). CONCLUSIONS: Our algorithm-oriented strategy is appropriate for the resection of HCC originating in the caudate lobe because of the acceptable surgical safety and curability.

Platelet recovery correlates parenchymal volume recovery after liver resection.

AIM: Platelet count seems to assess liver function and predict liver regeneration, but factors associated with liver regeneration remain unclear. This study analyzed the relationship between platelet recovery and postresection liver regeneration. METHODS: Data from 343 candidates from 1245 consecutive patients with liver resection of more than Couinaud's segments were analyzed. Patients were divided into a low-platelet-recovery rate (LPRR) group (lowest 25%) or a control group on the basis of the platelet recovery rate on postoperative day (POD)7. Data were matched before analysis to adjust for operation scale. Trends in liver functional recovery were assessed, and liver volume recovery and remnant ischemic area was calculated using computed tomography volumetry. Factors predicting liver regeneration were analyzed. RESULTS: In 78 matched-pair patients, the all-complications rate (42.3% vs. 26.9%, P = 0.002) and infectious complications rate (21.8% vs. 9.0%, P = 0.027) were significantly higher in the LPRR group than in controls. Trends in liver functional recovery did not differ significantly, whereas significant differences remained for platelet recovery. Parenchyma volume recovery was delayed in the LPRR group from POD7 (84.5% vs. 78.1, P < 0.01) to POD30 (92.5% vs. 85.6, P < 0.01). Platelet recovery rate on POD7 correlated negatively with ischemic liver volume as evaluated on POD2 by computed tomography (r = 0.691). Postoperative ischemic volume on POD2 (5.41 [1.98-11.21], P < 0.001), infectious complications (3.48 [1.44-7.37], P < 0.001), and multiple resection (1.67 [1.10-4.11], P = 0.011) predicted delayed platelet recovery rate on multivariate analysis. CONCLUSION: Platelet recovery correlated with liver volume recovery and occurrence of complications. Large ischemic area might negatively impact regeneration after liver resection.

Patients' prognosis of intrahepatic cholangiocarcinoma and combined hepatocellular-cholangiocarcinoma after resection.

Combined hepatocellular-cholangiocarcinoma (cHCC-CC) and intrahepatic cholangiocarcinoma (ICC) are classified into one category, but comparison of prognosis of the two carcinomas remains controversial. The aim of the current study was to investigate surgical outcomes for patients with ICC or cHCC-CC who underwent resection in order to elucidate whether the classification of ICC and cHCC-CC is justified. Subjects were 61 patients with ICC and 29 patients with cHCC-CC who underwent liver resection from 2001 to 2017. Clinic-pathological data from the two groups were compared. Tumor number and vascular invasion were independent risk factors for recurrence-free survival (RFS) in both groups (P < .001 for both). Of note, for patients with ICC, tumor cut-off size of 5 cm showed statistical significance in median RFS (>5 cm vs ≤5 cm, 0.5 years vs 4.0 years, P = .003). For patients with cHCC-CC, tumor cut-off size of 2 cm showed statistical significance in median RFS (>2 cm vs ≤2 cm, 0.6 years vs 2.6 years, P = .038). The median RFS of patients with cHCC-CC was 0.9 years (95% confidence interval: 0.3-1.6), which was poorer than that of patients with ICC (1.3 years, 0.5-2.1) (P = .028); the rate of RFS at 5 years was 0% and 37.7% respectively. Our study supports the concept of classifying ICC and cHCC-CC into different categories because of a significant difference in RFS between the two.

Neither ischemic parenchymal volume nor severe grade complication correlate transient high transaminase elevation after liver resection.

To clarify whether high transient elevation of serum transaminase predicts severe complications and is related to the ischemic area on CT. Postoperative laboratory data and ischemia area on CT were analyzed on the basis of the presence of high transaminase elevation (aspartate aminotransferase (AST) > 1,000 IU/L within postoperative day (POD) 2 after liver resection. In the high elevation group, volume of ischemic areas was assessed by CT on POD2. The 538 patients were divided into a high transaminase group (n = 51) and a control group (n = 487). Median operation time (527 min vs. 360 min, p < 0.01) and liver ischemia time (121 min vs. 70 min, p < 0.01) were significantly longer, and intraoperative blood loss (478 mL [85-1572 mL] vs. 269 mL [5-4491 mL], p < 0.01) was significantly greater in the high transaminase group. No significant differences observed in frequency of severe complications (Clavien-Dindo classification Grade III or more) or postoperative hospitalization. Operation time (> 500 min; odds ratio (OR), 4.86; 95% confidence interval (CI), 2.40-9.89; p < 0.01) and liver ischemia time (> 120 min; OR, 3.47; 95%CI, 1.67-7.17; p < 0.01) were independent predictors of high transaminase elevation. No relationship was observed between degree of transaminase elevation and ischemic area (correlation coefficients: AST, R2 < 0.001; alanine aminotransferase, R2 = 0.005) CT volumetry on POD2. In conclusions, high transaminase elevations do not predict severe complications or reflect remnant ischemic area.

NMR measurement system including two synchronized ring buffers, with 128 rf coils for in situ water monitoring in a polymer electrolyte fuel cell.

A small radio-frequency (rf) coil inserted into a polymer electrolyte fuel cell (PEFC) can be used to acquire nuclear magnetic resonance (NMR) signals from the water in a membrane electrode assembly (MEA) or in oxygen gas channels in the PEFC. Measuring the spatial distribution of the water in a large PEFC requires using many rf probes, so an NMR measurement system which acquires NMR signals from 128 rf probes at intervals of 0.5 s was manufactured. The system has eight rf transceiver units with a field-programmable gate array (FPGA) for modulation of the excitation pulse and quadrature phase detection of the NMR signal, and one control unit with two ring buffers for data control. The sequence data required for the NMR measurement were written into one ring buffer. The acquired NMR signal data were then written temporarily into the other ring buffer and then were transmitted to a personal computer (PC). A total of 98 rf probes were inserted into the PEFC that had an electrical generation area of 16 cm × 14 cm, and the water generated in the PEFC was measured when the PEFC operated at 100 A. As a result, time-dependent changes in the spatial distribution of the water content in the MEA and the water in the oxygen gas channels were obtained.

Screening and surveillance for occupational cholangiocarcinoma in workers exposed to organic solvents.

PURPOSE: This study aimed to establish an efficient strategy for screening and surveillance for occupational cholangiocarcinoma. METHODS: We evaluated the consecutive changes in laboratory findings during regular health examinations and in abdominal ultrasonography findings before the diagnosis of occupational cholangiocarcinoma in nine patients. The results of laboratory tests and abdominal ultrasonography at the time of diagnosis were also examined. RESULTS: In all patients, the serum γ-glutamyl transpeptidase (γ-GTP) activity increased several years before the diagnosis of cholangiocarcinoma. The serum alanine aminotransferase (ALT) activity also increased several years before the diagnosis, following an increase in the serum aspartate aminotransferase (AST) activity in most patients. Abdominal ultrasonography before the diagnosis revealed regional dilatation of the bile ducts, which continued to enlarge. At the time of diagnosis, the γ-GTP, AST, and ALT activities were increased in nine, seven, and seven patients, respectively. The regional dilatation of bile ducts without tumor-induced stenosis, dilated bile ducts due to tumor-induced stenosis, space-occupying lesions, and/or lymph node swelling were observed. The serum concentrations of carbohydrate antigen 19-9 (CA 19-9) and/or carcinoembryonic antigen (CEA) were increased in all patients. CONCLUSIONS: Regular health examinations with a combination of ultrasonography and laboratory tests including the γ-GTP, AST, ALT, CA 19-9, and CEA levels are useful for screening and surveillance for occupational cholangiocarcinoma.

Characteristics of printing company workers newly diagnosed with occupational cholangiocarcinoma.

BACKGROUND: Cholangiocarcinoma has been reported in workers exposed to chlorinated organic solvents and has consequently been classified as an occupational disease (occupational cholangiocarcinoma) by the Japanese Ministry of Health, Labour and Welfare. This study aimed to identify the characteristics of nine workers newly diagnosed with occupational cholangiocarcinoma. METHODS: This study was a retrospective study conducted in 13 hospitals and three universities. Clinicopathological findings of nine occupational cholangiocarcinoma patients from seven printing companies in Japan were investigated and compared with 17 cholangiocarcinoma patients clustered in a single printing company in Osaka. RESULTS: Patient age at diagnosis was 31-57 years. Patients were exposed to 1,2-dichloropropane and/or dichloromethane. Serum γ-glutamyl transpeptidase activity was elevated in all patients. Regional dilatation of the intrahepatic bile ducts without tumor-induced obstruction was observed in two patients. Four patients developed intrahepatic cholangiocarcinoma and five developed hilar cholangiocarcinoma. Biliary intraepithelial neoplasia and/or intraductal papillary neoplasm of the bile duct was observed in four patients with available operative or autopsy specimens. CONCLUSIONS: Most of these patients with occupational cholangiocarcinoma exhibited typical findings, including high serum γ-glutamyl transpeptidase activity, regional dilatation of the bile ducts, and precancerous lesions, similar to findings previously reported in 17 occupational cholangiocarcinoma patients in Osaka.

Local electronic properties at organic-metal interfaces: thiophene derivatives on Pt(111).

The valence electronic states of thiophene (TP), 2-thiophenethiol (TT), 2,2'-bithiophene (BTP), and 2,2'-bithiophene-5-thiol (BTT) on Pt(111) were measured by ultraviolet photoemission spectroscopy (UPS) and metastable atom electron spectroscopy (MAES) to elucidate how the local electronic properties at the organic-metal interface are altered by the extent of π-conjugation and substituent effects. First-principles calculations using density functional theory (DFT) were used to assign the observed spectra. TP and BTP chemisorb weakly on Pt(111), whereas TT and BTT are strongly bound to Pt(111) through the S atom with the cleavage of the S-H bond, forming a thiolate. In the MAES spectra, weak emission just below the Fermi level (E(F)) was attributed to a chemisorption-induced gap state (CIGS) produced by orbital mixing between the organic species and Pt(111). The formation of CIGS is responsible for a metallic structure at the organic-metal interface. The relative intensities of CIGSs at E(F) were in the order of TP (flat-lying configuration) > TT > TP (inclined configuration), indicating that the spatial distribution of CIGSs is drastically altered by the strength of the organic-metal bond and the adsorption geometry. In other words, TP (flat-lying geometry) and TT serve as good mediators of the extension of the metal wave function at E(F), which would be closely related to charge transport at organic-metal interfaces.

Chemisorption-induced gap states at organic-metal interfaces: benzenethiol and benzeneselenol on metal surfaces.

Valence electronic states of benzenethiol (C(6)H(5)SH) and benzeneselenol (C(6)H(5)SeH) in the gas, condensed, and chemisorbed phases were examined by ultraviolet photoemission spectroscopy, metastable atom electron spectroscopy, and first-principles calculations using density functional theory. C(6)H(5)SH is chemisorbed on Pt(111) and Au(111) substrates to form a thiolate (C(6)H(5)S), and C(6)H(5)SeH is bound on Pt(111) substrate to form a selenolate (C(6)H(5)Se). In all cases, chemisorption-induced gap states (CIGSs) appear just below the Fermi level (E(F)) of the substrate, yielding a metallic character around the anchor S and Se atoms. However, the local density at E(F) decreases considerably from the anchor atom to the benzene ring, because strong coupling between benzene π(1e(1g)) and S 3p(or Se 4p) in free molecules is apparently lifted upon chemisorption. In other words, thiolates and selenolates (especially C(6)H(5)S on Au(111)) act as poor mediators of the metal wave functions at E(F), which is closely related to electric conductance in the relevant metal-organic-metal junctions at zero bias.

Resection of solitary metachronous lymph node metastasis from hepatocellular carcinoma following transarterial chemotherapy with cisplatin: a case report.

A 74-year-old female was found to have a 40-mm liver tumor (in segment VIII) by ultrasonography and was diagnosed with hepatocellular carcinoma (HCC). She underwent liver resection and was stably treated without recurrence for 19 months. A 45-mm extrahepatic tumor was then found during follow-up with enhanced computed tomography and was diagnosed as being a metachronous lymph node (LN) metastasis. Angiography revealed that the metastasis LN was fed by both the right and left gastric arteries. Transarterial chemotherapy with cisplatin was scheduled to control LN metastasis and to prevent intrahepatic metastasis, simultaneously. Blood alteration using coil embolization was performed to isolate the feeding arteries before transarterial chemotherapy with cisplatin powder. The patient was stably treated for 6 months (3 times) and no new intra- or extrahepatic metastatic lesions appeared during the chemotherapy. The patient subsequently underwent systematic LN dissection of the porta hepatis. She was successfully treated, and has remained recurrence-free for almost 5 years.

[A case of rectal cancer with sacrum metastasis treated with S-1 leading to a complete response].

The patient is a 47-year-old female. She had undergone abdominoperineal resection for rectal cancer at 39 years of age. Two years and 9 months after surgery, she was diagnosed with a vagina invasion. Radiation therapy and chemotherapy (UFT/ LV) were performed. After 4 courses of UFT/LV, a complete response (CR) was noted. Four years and 3 months after surgery, she was diagnosed with a sacrum metastasis. Chemotherapy with S-1 was performed. After 2 courses of S-1, a CR was noted. There has been no recurrence sign to date.

Afferent loop obstruction after distal gastrectomy with Roux-en-Y reconstruction.

BACKGROUND: The incidence of afferent loop obstruction after gastrectomy with Roux-en-Y reconstruction has not yet been reported. The aim of this study was to elucidate the incidence of afferent loop obstruction after distal gastrectomy with Roux-en-Y reconstruction performed through an open approach. METHODS: We conducted a retrospective review of the data of 1908 patients who underwent distal gastrectomy followed by Roux-en-Y reconstruction through an open approach between January 1999 and December 2008. RESULTS: Four patients (0.2%) developed afferent loop obstruction. The median age of the patients, consisting of three men and one woman, was 64 years (range 46-78 years). The cause of the afferent loop obstruction was internal herniation in two patients, adhesion in one patient, and peritoneal recurrence in one patient. The internal herniation occurred at the mesenteric gap in the region of the jejunojejunostomy. The interval between the initial gastrectomies and the emergency operations for afferent loop obstruction ranged from 3 weeks to 2 years (median 5 months). Three of the four patients were symptomatic, with vomiting and abdominal pain. All patients recovered following the emergency operations, and none died of this complication. CONCLUSIONS: Afferent loop obstruction develops rarely after distal gastrectomy with Roux-en-Y reconstruction through an open approach. This rare but fatal complication should be considered when a patient complains of abdominal pain and/or vomiting after distal gastrectomy with Roux-en-Y reconstruction.

Phenylalanine breath test as a method to evaluate hepatic dysfunction in obstructive jaundice.

BACKGROUND: The purpose of this study was to investigate whether the hepatic dysfunction associated with obstructive jaundice can be measured from changes in expiratory 13CO2 levels after intravenous administration of l-[1-(13)C]phenylalanine, using a rat model of obstructive jaundice. MATERIALS AND METHODS: Under pentobarbital anesthesia, bile duct ligation (BDL) was performed (n=12). In the control group, simple laparotomy was performed (n=12). On postoperative day 7, 20 mg/kg l-[1-(13)C]phenylalanine was administered via the femoral vein. Phenylalanine breath test (PBT) was performed for 30 min. We compared single point of 13CO2 level (SPT: T: min) and sum of 13CO2 output (ST) values between BDL and control rats. We examined the correlation of SPT or ST with phenylalanine hydroxylase activity (PHA) and blood chemical parameters. RESULTS: Both SPT and ST values decreased in BDL compared to control 3 min after the start of PBT (SP10; 103+/-12 (per thousand) versus 84+/-16 (per thousand) P=0.025). PHA/g liver in BDL was significantly decreased compared to control (40.81+/-4.80 (U) versus 28.93+/-9.60 (U) P=0.008). PHA/g liver was correlated with SPT with correlation coefficient of more than 0.715, 10 min after the start of PBT, and the maximum correlation was at SP20 (r=0.801). Blood chemical parameters were correlated with S15 (total bilirubin, r=-0.717; alkaline phosphatase, r=-0.841; gamma-glutamyl transpeptidase, r=-0.759; alanine aminotransferase, r=-0.776; albumin, r=0.819). CONCLUSIONS: In the breath test with intravenously l-[1-(13)C]phenylalanine, hepatic dysfunction associated with obstructive jaundice could be measured in a short period.

Ornithine breath test as a method to evaluate functional liver volume.

BACKGROUND: The purpose of this study was to investigate whether the functional liver volume can be measured from changes in expiratory 13CO2 levels after intravenous administration of L-[1, 2-13C] ornithine, using a rat model of hepatectomy. MATERIALS AND METHODS: Under pentobarbital anesthesia, 30%, 70%, or 90% hepatectomy was performed. In the control group, simple laparotomy was performed. Then, 20 mg/kg L-[1, 2-13C] ornithine was administered to rats via the femoral vein. A breath test was conducted 20 min after laparotomy. We examined the correlation of the sum of 13CO2 output (S) or a single point of 13CO2 level (SP) with liver weight/body weight (LW/BW) (%) every 15 min. RESULTS: In all of the groups, the ornithine breath test (OBT) graph reached a plateau level at about 6 min. The correlation coefficient between S15 and LW/BW was highest 0.952 (P <0.0001). The correlation coefficient between SP14 and LW/BW was highest, 0.944 (P <0.0001). The severity of hepatic injury could be evaluated, with significant differences in S5-15 and SP5-15 in all comparisons between groups. CONCLUSION: In the breath test with intravenously administered L-[1, 2-13C] ornithine, functional liver volume could be evaluated accurately in a short period.

Patients with severe liver cirrhosis followed up by L-[1-(13)C] phenylalanine breath test.

Compared to healthy subjects, patients with severe liver cirrhosis (LC) are reported to show lower values in the L-[1-(13)C] phenylalanine breath test (PBT). We performed this test several times during the clinical course in two patients with severe liver cirrhosis (LC). Patient 1 was a 67-year-old woman with non-B, non-C LC and hepatocellular carcinoma (HCC) in the lateral hepatic segment. Because the patient wanted to receive nonsurgical treatment for HCC, intraarterial administration of zinostatin stimalamer was performed. The patient was hospitalized four times before her death from liver failure on December 20, 2000. During her clinical course, PBT was performed four times. Values for both the rate of hepatic phenylalanine oxidation (%(13)C dose h(-1)) and %(13)C cumulative excretion gradually decreased during her clinical course. Patient 2 was a 57-year-old man with hepatitis C virus (HCV)-positive LC. He was hospitalized seven times between December 1998 and his death on May 24, 2001. During his clinical course, PBT was performed four times. Values for both %(13)C dose h(-1) and %(13)C cumulative excretion decreased during his clinical course. We confirmed that PBT was useful for following the course of LC.

L-[1-13C] phenylalanine breath test reflects histological changes in the liver.

OBJECTIVE: Compared with healthy individuals, patients with chronic liver disease reportedly have lower L-[1-13C] phenylalanine breath test (PBT) values. However, there is no report detailing the relationship between the results of PBT and pathological data in liver disease patients. This study was designed to investigate the degree of histological changes in the liver that induce PBT changes and the time of measurement that reflects the histological change. MATERIALS AND METHODS: PBT was performed in 47 patients (10 with a normal liver, and 37 with chronic hepatitis C). After administering 10 mg/kg L-[1-13C] phenylalanine, 300 mL of expired air was collected over 90 min at 15-min intervals. The rate of hepatic phenylalanine oxidation (%13C dose h(-1)) at each time point was calculated from the amount of 13CO(2) in the exhaled air, assuming a CO(2) production rate of 300 mmol m(-2) body surface area per hour. Subsequently, we examined the relationship between the results of PBT and METAVIR pathological scoring. RESULTS: The highest correlation coefficients between the fibrosis score and %13C dose h(-1) and between the fibrosis score and %13C cumulative excretion were obtained at 45 min (r = -0.779, R(2) = 0.607; P < 0.0001) and 75 min (r = -0.768, R(2) = 0.590; P < 0.0001), respectively. CONCLUSION: PBT is a useful adjunct for detecting histological changes in the liver. The %13C dose h(-1) value at 45 min and the %13C cumulative excretion value at 75 min of PBT are useful for detecting hepatic histological change.

L-[1-13C] phenylalanine breath test reflects phenylalanine hydroxylase activity of the whole liver.

OBJECT: The purpose of this study was to perform L-[1-13C] phenylalanine breath test (PBT), measure phenylalanine hydroxylase (PAH) activity in liver tissue biopsies from patients, analyze the relationship between PBT results and PAH activity, and determine the time point at which measurements best reflect PAH activity in liver tissue. METHODS: PBT was performed in 25 patients (10 with normal liver and 15 with liver cirrhosis). After administering 10 mg/kg L-[1-13C] phenylalanine, 300 ml of expired air was collected over 90 min at 15-min intervals. The rate of hepatic phenylalanine oxidation (%13C dose h(-1)) at each time point was calculated from the amount of 13CO(2) in the breath, assuming a CO(2) production rate of 300 mmol m(-2) body surface area per hour. Subsequently, we examined the relationship between the results of PBT and PAH activity. RESULTS: PAH activity of the whole liver was significantly decreased in hepatic cirrhosis patients (P < 0.05). The results of PBT %13C dose h(-1) correlated with the PAH activity/liver, with correlation coefficients at 30, 45, and 60 min of more than 0.7, and the maximum correlation was at 30 min (r = 0.821, P < 0.0001). %13C cumulative excretion correlated with the PAH activity/liver with correlation coefficients of more than 0.7 after 45 min. The maximum correlation was at 90 min (r = 0.770, P = 0.001). CONCLUSION: PBT values reflect PAH activity in the whole liver and, in particular, the % dose h(-1) at 30 min after oral administration highly correlates with PAH activity, providing an important indicator for monitoring changes in whole liver PAH activity.