Identification of galacturonic acid-rich polysaccharide with intestinal immune system modulating activity via Peyer's patch from postbiotics of Phellinus linteus mycelial submerged culture.

Interests in the development and exploration of industrial applications of medicinal mushrooms as postbiotics have lately increased. We recently reported the potential use of Phellinus linteus mycelial-containing whole culture extract (PLME) prepared by submerged cultivation as a postbiotic that promotes immune system activation. Here, we aimed to isolate and structurally elucidate the active ingredients in PLME by activity-guided fractionation. The intestinal immunostimulatory activity was evaluated by bone marrow (BM) cell proliferation activity and related cytokine production in C3H-HeN mouse-derived Peyer's patch (PP) cells treated with polysaccharide fractions. The initially crude polysaccharide (PLME-CP) of PLME prepared using ethanol precipitation was further fractionated into four fractions (PLME-CP-0 to -III) by anion-exchange column chromatography. BM cell proliferation and cytokine production of PLME-CP-III were significantly improved compared to those of PLME-CP. PLME-CP-III was then fractionated into PLME-CP-III-1 and PLME-CP-III-2 by gel filtration chromatography. Based on the molecular weight distribution, monosaccharide, and glycosyl linkage analyses, PLME-CP-III-1 was revealed as a novel galacturonic acid-rich acidic polysaccharide and further shown to play an important role in facilitating PP-mediated intestinal immunostimulatory activity. This is the first study demonstrating the structural characteristics of a novel intestinal immune system modulating acidic polysaccharide from P. linteus mycelium-containing whole culture broth postbiotics.

Immunostimulatory Effect of Postbiotics Prepared from Phellinus linteus Mycelial Submerged Culture via Activation of Spleen and Peyer's Patch in C3H/HeN Mice.

Medicinal mushrooms are an important natural resource promoting health benefits. Herein, Phellinus linteus mycelia were prepared under submerged cultivation, the mycelium-containing culture broth was extracted as a whole to obtain the postbiotic materials (PLME), and its effect on the immune system was evaluated in normal C3H/HeN mice. Oral administration of PLME for 4 weeks was well tolerated and safe. In the PLME-administered groups, in addition to the production of immunostimulatory cytokines, such as interferon gamma (IFN-γ), tumor necrosis factor-α (TNF-α), and interleukin 6 (IL-6), the mitogenic activity was significantly increased. PLME administration also significantly increased the levels of serum immunoglobulin G (IgG) and IgA in the small intestinal fluid and Peyer's patches and enhanced Peyer's patch-mediated bone marrow cell proliferation activity and cytokine production (IL-2, IL-6, and IFN-γ). Histomorphometric analyses showed an increase in immune cells in the spleen and small intestinal tissues of mice administered PLME, supporting the rationale for its immune system activation. PLME mainly contained neutral sugar (969.1 mg/g), comprising primarily of glucose as a monosaccharide unit. The ß-glucan content was 88.5 mg/g. Data suggest that PLME effectively promote immune function by stimulating the systemic immune system through the spleen and intestinal immune tissues. PLME can thus be developed as a functional ingredient to enhance immune functions.

Effect of Enzymatic Treatment of Chrysanthemum indicum Linné Extracts on Lipid Accumulation and Adipogenesis in High-Fat-Diet-Induced Obese Male Mice.

Enzyme treatment of the foods and herbs has been used to improve the absorption rate the efficiency of plant extracts by converting the glycosides of the plant into aglycones. In this study, we examined the obesity-inhibitory effect of Chrysanthemum indicum Linné (CI) treated with enzymes such as viscozyme and tannase, which are highly efficient in converting glycosides to aglycones and then compared with untreated CI extract. The enzyme-treated CI ethanol extract (CIVT) was administered orally at various doses for 7 weeks in the high fat diet (HFD)-fed male mice. CIVT administration reduced the body weights, the food efficiency and the serum levels of lipid metabolism-related biomarkers, such as triglycerides (TG), total cholesterol (TC), low-density lipoprotein cholesterol (LDL-c) and leptin in the dose-dependent manner but not those high-density lipoprotein cholesterol (HDL-c) and adiponectin. CIVT also reduced considerably the total lipid amount in the liver and the size of adipocytes in the epididymal white adipose tissue (eWAT). CIVT effectively downregulated the adipogenesis-related transcription factors such as peroxisome proliferation activated receptor (PPAR)-γ and CCAAT/enhancer binding protein-α (C/EBP-α) but up-regulated PPAR-α, in the liver and eWAT. In addition, when compared to the enzyme-untreated CI 50% ethanol extract (CIEE), CIVT enhanced the reduction of body weight and lipid accumulation. Moreover, the viscozyme and tannase treatment of CI increased the flavonoid contents of the aglycone form. Therefore, our results support that the enzymatic treatment induced the production of aglycones for potentially suppressing the adipogenesis and lipid accumulation in HFD-fed mice. It suggests that CIVT might be an effective candidate for attenuating the over-weight and its related diseases.

Chrysanthemum indicum L. ethanol extract reduces high-fat diet-induced obesity in mice.

The present study was undertaken to investigate the mechanism behind the anti-obesity effect of the 50% ethanol extract of Chrysanthemum indicum L. flowers (CIEE) in a mouse model of high-fat diet (HFD)-induced obesity. Male C57BL/6J mice (six mice in each group) were administered CIEE (8, 40 and 200 mg/kg) for 6 weeks while being fed with a HFD. Garcinia cambogia (GC) was used as the positive control and was administered in the same manner as CIEE. Results demonstrated that oral administration of CIEE significantly reduced body weight, epididymal white adipose tissue (EWAT), liver weight and serum levels of total cholesterol and triglyceride (P<0.05). In addition, CIEE reduced serum leptin and increased adiponectin levels. CIEE significantly downregulated peroxisome proliferator-activated receptor γ (PPARγ), CCAAT/enhancer-binding protein-α and fatty acid synthase expression levels in EWAT, and upregulated the protein expression of PPARα in liver tissue of HFD-fed obese mice (P<0.05). These results suggested that Chrysanthemum indicum L. flowers may be a potentially effective therapeutic agent for obesity and its associated complications.

Clinical significance of pancreatic intraepithelial neoplasia in resectable pancreatic cancer on survivals.

PURPOSE: Noninvasive precursor lesions for pancreatic adenocarcinoma include pancreatic intraepithelial neoplasia (PanIN), intraductal papillary mucinous neoplasm, and mucinous cystic neoplasm. PanIN is often found synchronously adjacent to resected pancreatic ductal adenocarcinoma (PDAC) tumors. However, its prognostic significance on outcome after PDAC resection is unknown. The purpose of the current study was to determine if the presence of PanIN has a prognostic or predictive effect on survival after resection for PDAC with curative intent. METHODS: We retrospectively reviewed the clinicopathologic data of patients who underwent pancreatectomy for PDAC from January 2002 to January 2013. Intraductal papillary mucinous lesions and mucinous cystic neoplasms were excluded. All available postoperative imaging and clinical follow-up data were reviewed. RESULTS: There were 95 patients who underwent pancreatectomy. Tumors were most commonly located in the pancreas head and as such pancreaticoduodenectomy was the most commonly performed operation. The median tumor size was 3.2 cm. An absence of PanIN lesions was identified in 39 patients (41%). Of the patients with PanIN lesions, high-grade PanIN (grade 3) was the most common type (64.3%) followed by grade 2 (28.6%). There was no significant difference in overall survival or disease-free survival between the non-PanIN and PanIN groups. CONCLUSION: The presence or absence of PanIN lesions did not affect survival in patients undergoing resection for pancreatic cancer. However, patients with high-grade PanINs tended to have better overall survival. Larger studies with longer follow up are needed to accurately determine its clinical significance.

Systematic review of the clinical significance of lymph node micrometastases of pancreatic adenocarcinoma following surgical resection.

OBJECTIVES: The aim of this study is to perform a systematic review of the clinical impact of lymph node micrometastasis in pancreatic adenocarcinoma following surgical resection. METHODS: A systematic review was conducted and published literature were searched using "pancreas or pancreatic" and "cancer or carcinoma or neoplasm", and "micrometastasis or micrometastses" in the PubMed, EMBAE, and Web of Science. RESULTS: Thirteen publications with 726 patients and 3701 lymph nodes were included in this systematic review. The detection method was immunohistochemical stains or polymerase chain reaction. The pooled proportion of patients with positive lymph node micrometastasis was 43.1% (95% Confidence interval (CI) 0.254-0.628). The pooled proportion of positive lymph node micrometastasis (number of positive lymph node micrometastasis/total number of lymph nodes examined) was 10.8% (95% CI 4.8-22.6). Among the conventional H &E negative patients, the reported 5-year survival rates of the patients without lymph node micrometastases vs. those with lymph node micrometastases in the ranged from 50% to 61% and from 0% to 36%, respectively Patients with lymph node micrometastasis showed poorer survival (Hazard ratio 4.29, 95% CI 1.27-14.41). CONCLUSIONS: The presence of lymph node micrometastasis is associated with poorer survival. Lymph node micrometastasis is applicable to stratify the risk of recurrence and the need for adjuvant therapy of post-resection patients with pancreatic adenocarcinoma in the conventional H & E lymph node negative patients.

VEGF Overexpression Predicts Poor Survival in Hepatocellular Carcinoma.

OBJECTIVE: The aim of this study was to investigate the clinicopathological and immunohistochemical (including VEGF, Akt, HSP70, and HSP20 expression) factors that affect the overall and disease-free survival of HCC patients following surgical resection. METHODS: 234 patients with HCC following surgical resection were enrolled. Clinicopathological and survival data were analyzed, and immunohistochemical staining was performed on tissue microarray sections using the anti-VEGF, anti-Akt, anti-HSP70, and anti-HSP27 antibodies. RESULTS: The 3- and 5-year overall survival rates were 86.5 and 81.54%, respectively. Multivariate analysis revealed that VEGF expression (P = 0.017, HR = 2.573) and T stage (P < 0.001, HR = 4.953) were independent prognostic factors for overall survival. Immunohistochemical staining showed that the expression of Akt, HSP70, and HSP27 did not affect the overall survival rate. The 3- and 5-year disease-free survival rates were 58.2 and 49.4%, respectively. Compared to the VEGF(-)/(+) group, the VEGF(++)/(+++) group demonstrated significantly higher proportion of patients with AFP levels > 400 ng/mL, capsule invasion, and microvascular invasion. CONCLUSION: VEGF overexpression was associated with capsule invasion, microvascular invasion, and a poor overall survival rate.

Current status and future perspective of laparoscopic surgery in hepatobiliary disease.

Recent advances in minimally invasive surgery include laparoscopic and robotic surgery. These surgical techniques have changed the paradigm of surgical treatment for hepatobiliary diseases. Minimally invasive surgery has the advantages of minimal wound extension for cosmetic effect, early postoperative recovery, and few postoperative complications in patients. For laparoscopic liver resection, the indications have been expanded and oncological outcome was proven to be similar with open surgery in the malignant disease. Laparoscopic cholecystectomy is a classical operation for benign gallbladder diseases and the effort to decrease the surgical wound resulted to perform single incision laparoscopic cholecystectomy. For choledochal cyst, laparoscopic surgery is applied gradually despite of the difficulties associated with anastomosis, and robotic surgery for hepatobiliary disease is also performed for more minimally invasive surgery; however, while admitting the advantage of robotic surgery, robotic technology should be improved for development of more convenient and cheaper instrument and continuous efforts to enhance surgical technique to overcome long operation is necessary. In this review, the status and future perspectives of minimally invasive surgery for hepatobiliary diseases are summarized and discussed.

Disease recurrence patterns and analysis of clinicopathological prognostic factors for recurrence after resection for distal bile duct cancer.

Surgical resection is the treatment of choice for bile duct cancers. The aim of this study was to investigate disease recurrence patterns and prognostic factors for recurrence of distal bile duct cancers after surgical resection. A retrospective study was performed on 122 patients with distal bile duct cancers who underwent R0 or R1 surgical resection at Korea University Guro Hospital from 1991 to 2010. Sites of initial disease recurrence were classified as locoregional or distant. Univariate and multivariate analyses were performed to investigate the factors affecting recurrence. Of the 122 patients, 80 patients developed recurrence. The disease-free survival rate was 63.1 per cent at one year and 36.4 per cent at three years. The patterns of recurrence at diagnosis were locoregional in 25 patients, locoregional and distant metastasis in 14 patients, and distant metastasis in 41 patients. Multivariate analyses revealed that recurrence pattern, lymph node metastasis, and differentiation are independent prognostic factors affecting disease-free survival. R status (marginal significance) and tumor differentiation were independent prognostic factors associated with locoregional recurrence. Differentiation and lymph node metastasis were independent prognostic factors associated with distant metastasis. The prognosis after recurrence was poor with a 1-year survival rate after recurrence of 26.1 per cent. Adjuvant chemo- or radiation therapy, delivered in patients mainly with R1 resection or with presence of lymph node metastasis, did not demonstrate the survival benefit. Significant factors for recurrence were tumor differentiation and lymph node metastasis. Therefore, close follow-up and adjuvant therapy will be necessary in patients with lymph node metastasis or poorly differentiated tumor.

Clinical characteristics of incidental or unsuspected gallbladder cancers diagnosed during or after cholecystectomy: a systematic review and meta-analysis.

AIM: To perform a systematic review of incidental or unsuspected gallbladder (GB) cancer diagnosed during or after cholecystectomy. METHODS: Data in PubMed, EMBASE, and Cochrane Library were reviewed and 26 publications were included in the meta-analysis. The inclusion criterion for incidental GB cancer was GB cancer diagnosed during or after cholecystectomy that was not suspected at a preoperative stage. Pooled proportions of the incidence, distribution of T stage, and revisional surgery of incidental GB cancer were analyzed. RESULTS: The final pooled population comprised 2145 patients with incidental GB cancers. Incidental GB cancers were found in 0.7% of cholecystectomies performed for benign gallbladder diseases on preoperative diagnosis (95%CI: 0.004-0.012). Nearly 50% of the incidental GB cancers were stage T2 with a pooled proportion of 47.0% (95%CI: 0.421-0.519). T1 and T3 GB cancers were found at a similar frequency, with pooled proportions of 23.0% (95%CI: 0.178-0.291) and 25.1% (95%CI: 0.195-0.317), respectively. The pooled proportion that completed revisional surgery for curative intent was 40.9% (95%CI: 0.329-0.494). The proportion of patients with unresectable disease upon revisional surgery was 23.0% (95%CI: 0.177-0.294). CONCLUSION: A large proportion of incidental GB cancers were T2 and T3 lesions. Revisional surgery for radical cholecystectomy is warranted in T2 and more advanced cancers.

Single-port laparoscopic distal pancreatectomy: initial experience.

INTRODUCTION: Laparoscopic distal pancreatectomy has become the standard treatment of choice for pancreatic tail cystic and solid tumors when technically feasible. Technological advances have led to the development of single-port laparoscopic surgery, a safe alternative procedure. We present our experiences with single-port laparoscopic distal pancreatectomy. MATERIALS AND METHODS: We retrospectively reviewed clinical records and compared clinical outcomes in 40 patients diagnosed with a pancreatic tail mass between 2007 and 2013 who received either conventional laparoscopic (n=28) or single-port laparoscopic distal pancreatectomy (n=12). RESULTS: The mean surgery time in the single-port group (279.8±53.0 minutes) was significantly longer than in the conventional group (186.9±86.6 minutes) (P=.001). The mean duration of postoperative hospital stay in the single-port group (12.2±5.4 days) was also significantly longer than in the conventional group (8.3±4.7 days) (P=.028). The spleen was preserved more in the conventional group (60.7%) than in the single-port group (33.3%), but the difference was not significant (P=.112). There were no significant differences in intraoperative blood loss, tumor size, conversion rate, or postoperative complications between the two groups. CONCLUSIONS: Blood loss and postoperative complications of single-port laparoscopic distal pancreatectomy are similar to those of conventional laparoscopic distal pancreatectomy. Single-port laparoscopic distal pancreatectomy can be performed safely and effectively in select patients with pancreas tail neoplasms, but is associated with a longer surgery time and postoperative hospital stay.

The efficacy of subcostal-approach laparoscopic cholecystectomy in patients with previous midline incisions: comparative analysis with conventional laparoscopic cholecystectomy.

BACKGROUND: In patients with previous abdominal surgery, difficulties in laparoscopic cholecystectomy (LC) are associated with adhesions from the previous surgery. We reported the efficacy of a subcostal-approach LC (SALC) in patients with previous midline incisions. SUBJECTS AND METHODS: Thirty-five patients with previous upper midline incision who underwent SALC from 2009 to 2013 at Korea University Medical Center (Seoul, Korea) were included. In SALC, a subcostal incision instead of an umbilical one was used to avoid adhesion in the midline scar. We compared the clinical outcomes of SALC with those of conventional LC in patients with previous midline incisions. RESULTS: In the SALC group, there were 25 men and 10 women. The mean age was 64 years. Median operative time was 60 minutes, and the median length of postoperative hospital stay was 2 days. Most of the patients underwent three-port cholecystectomy. Three patients underwent conversion to open surgery. The SALC group had a significantly shorter postoperative hospital stay and shorter operation time compared with the conventional LC (with supraumbilical incision) group. CONCLUSIONS: SALC is a safe and effective procedure for patients who have had a previous midline incision that can help prevent unnecessary adhesiolysis.

Influence of clinically significant portal hypertension on surgical outcomes and survival following hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis.

Surgical resection is not indicated in patients with portal hypertension in the current guideline of Barcelona Clinic Liver Cancer (BCLC) stage. We report a systematic review and meta-analysis to determine the impact of clinically significant portal hypertension on survival in patients with hepatocellular carcinoma (HCC) following hepatectomy. Searched data in PubMed, EMBASE, and the Cochrane Library were reviewed and 11 publications were included in the meta-analysis. The inclusion criteria of clinically significant portal hypertension were esophageal varices and/or thrombocytopenia with splenomegaly. Pooled data were extracted and computed into odds ratios (ORs) for clinical outcome and hazard ratios (HRs) for overall survival. The final pooled data were composed of 2,285 patients. There were 775 patients with clinically significant portal hypertension (PHT group) and 1,510 patients without clinically significant portal hypertension (non-PHT group). Pooled proportion of mortality was 6.1% (95% confidence interval [CI] 0.032-0.116) in PHT group and 2.8% (95% CI 0.014-0.054) in the non-PHT group. The pooled proportion of morbidity was 41.7% (95% CI 0.274-0.575) in PHT group and 34.7% (95% CI 0.243-0.467) in non-PHT group. Pooled data confirmed a significantly higher postoperative mortality in the PHT group, with OR 3.02 (P < 0.001). The PHT group also demonstrated significantly higher occurrence of postoperative complications (OR 1.39, P = 0.008), liver-related morbidity (OR 3.10, P < 0.00001), and liver failure (OR 2.14, P = 0.0005) compared to the non-PHT group. According to the overall survival, pooled analysis demonstrated that the PHT group demonstrated poorer survival than the non-PHT group (HR 1.48, P = 0.007). The analyses support significantly higher rates of postoperative mortality, complications, liver-related morbidity, liver failure, and poorer overall survival in PHT group compared with the non-PHT group. Surgical resection should be selected carefully with strict surgical strategy in patients with clinically significant portal hypertension when surgical resection is planned.

Clinicopathological analysis and survival outcome of duodenal adenocarcinoma.

Duodenal adenocarcinoma is a rare cancer, contributing <10 % of periampullary carcinoma. This study reviews the single center experience of duodenal adenocarcinoma and analyzes the clinical and pathological factors to predict survival and recurrence. The records of 50 patients with duodenal adenocarcinoma who underwent surgical exploration or resection from 1995 to 2010 were reviewed retrospectively. Univariate and multivariate analyses were performed to identify the clinicopathological factors associated with survival and recurrence. There were 35 men and 15 women, with a mean age of 61 years. In multivariate analysis of 50 patients, R0 resection [p = 0.041, hazard ratio (HR) = 3.569, 95% confidence interval (CI) = 1.057-12.054] and symptom at initial admission (p = 0.025, HR = 11.210, 95% CI = 1.354-92.812) were independent prognostic factors for overall survival. Thirty-six patients underwent curative resection (resectability 72%). The 5-year survival rates for curative and noncurative resections were 46.4% and 0%, respectively. Univariate analysis of 36 patients who underwent R0 resection revealed that symptoms at initial admission (p = 0.023), presence of lymph node metastasis (p = 0.034), and perineural invasion (p = 0.025) were significant prognostic factors after curative resection. There was no significant factor for overall survival in the multivariate analysis. There was recurrence in 15 patients, mainly as liver metastasis. Multivariate analysis revealed that presence of symptom (p = 0.047, HR = 5.362, 95% CI = 1.021-28.149) and ulcerative tumor (p = 0.036, HR = 5.668, 95% CI = 1.123-28.619) were independent factors for disease free survival. An aggressive surgical approach to achieve R0 resection was important to enhance survival. Most of the recurrence occurred within 1 year after surgery. Close follow-up is necessary after surgical resection.

Surgical strategy for T2 and T3 gallbladder cancer: is extrahepatic bile duct resection always necessary?

PURPOSE: Resection of the extrahepatic bile duct is not performed uniformly in gallbladder cancer. The study investigated the clinical significance of resection of extrahepatic bile duct (EHBD) in T2 and T3 gallbladder cancer. METHODS: Between 2000 and 2010, 71 T2 or T3 gallbladder cancer patients who underwent R0 resection at Korea University Medical Center were included. Clinicopathological data were reviewed retrospectively. Survival analysis and comparison between EHBD resection and non-resection groups were performed. RESULTS: The 32 men and 39 women had 49 T2 tumors and 22 T3 tumors. The overall survival rate was 67.8 % at 3 years and 47.2 % at 5 years. In multivariate analysis for overall survival, lymphovascular invasion and lymph node metastasis were significant independent predictors. Comparing the patients according to EHBD resection, the EHBD resection group demonstrated significantly longer hospital stay, longer operative time, more transfusion requirement, more extensive liver resection, and less treatment of neoadjuvant therapy. Significantly higher proportions of perineural invasion and lymph node metastasis were noted in the EHBD resection group. There were no statistically significant differences in survival between the EHBD resection and non-resection groups. CONCLUSIONS: Resection of extrahepatic bile duct was not always necessary in T2 and T3 cancers. However, the patients who undergo resection of extrahepatic bile duct tended to have more aggressive tumor characteristics and undergo more aggressive surgical approach. To enhance overall survival for the patients with T2 and T3 gallbladder cancers, surgeons should try to perform R0 resection including EHBD resection.

Surgical stress response and clinical outcomes of single port laparoscopic cholecystectomy: prospective nonrandomized study.

The levels of interleukin-6 (IL-6) are proportionate to injury; it is the most commonly used quantitative marker in surgical studies. Cytokines and the acute-phase response play an important role in controlling the human immune system. The objective of this study was to compare the systemic acute cytokine response and clinical outcomes of conventional laparoscopic and single port laparoscopic cholecystectomy. We compared patients who underwent single port laparoscopic cholecystectomy (the single port group) with patients who underwent conventional laparoscopic cholecystectomy (the conventional group) according to the clinical variables, IL-6, leukocyte subpopulations, and visual analog scale (VAS) pain score. The mean age in the single port group was significantly younger (P = 0.010) and the mean operation time in the conventional group was significantly shorter (P = 0.002). Postoperative 4-hour VAS pain score was slightly worse in the single port laparoscopic cholecystectomy group, but was not significantly different. We found no difference in clinical outcomes, the level of serum IL-6, C-reactive protein, leukocyte subpopulations, and complications between the two groups. Stress response in single port laparoscopic cholecystectomy is equal to conventional surgery. Postoperative 4-hour VAS pain score was slightly worse and the operation time is significantly longer in the single port laparoscopic cholecystectomy group.