Performance evaluation of bactericidal effect and endotoxin inactivation by low-temperature ozone/hydrogen peroxide mixed gas exposure.

This study evaluated the performance of a new O3 /H2 O2 mixed gas sterilization instrument for killing microorganisms and inactivating bacterial endotoxin at low temperatures. Sterility assurance level was achieved by an over 6-log reduction of Geobacillus stearothermophilus ATCC 12980, and the decimal reduction value was 0.77 min in sterilization mode. A reduction of over 3 logs in Limulus amebocyte lysate coagulation activity of purified endotoxin from Escherichia coli was observed after treatment in endotoxin-inactivation mode. The same inactivation ability was observed when treating dried bacterial cells. Biomaterials made of polymer or metal did not exhibit cytotoxicity after gas exposure at O3 concentrations below 200 ppm. As the results of human cell-based pyrogen testing, significant amounts of endotoxin that were over the limit for medical devices contacting cerebrospinal fluid (2.15 EU/device) were detected on scissors washed with a washer-disinfector and sterilized with ethylene oxide or autoclaving. In contrast, endotoxin decreased to 0.29 ± 0.05 EU/device after O3 /H2 O2 mixed gas sterilization in endotoxin-inactivation mode. Compared to conventional gas sterilization methods, O3 /H2 O2 mixed gas has high sterilization ability and a strong capacity to inactivate endotoxin. It is expected that this sterilization technology will improve the safety of reusable medical devices and utensils for regenerative medicine.

Oral fluoropyrimidine may augment the efficacy of aromatase inhibitor via the down-regulation of estrogen receptor in estrogen-responsive breast cancer xenografts.

The present preclinical study was designed to evaluate a new combination therapy comprised of the aromatase inhibitor anastrozole (ANA) and the oral fluoropyrimidines, UFT and S-1 against the estrogen receptor (ER)-positive human breast cancer cell line MCF-7/Arom 14, which was stably transfected with the cDNA of human aromatase. MCF-7/Arom 14 cells showed a high aromatase activity and notably were able to grow in the presence of testosterone and estradiol (E(2)) in vitro. ANA and 5-fluorouracil (5-FU) inhibited cell growth at concentrations of 0.005-10 and 0.2-5 µM, respectively, and the combination of both drugs additively inhibited cell growth. The growth of MCF-7/Arom 14 tumors was significantly inhibited by ANA and S-1 or UFT in vivo. The combination of ANA with S-1 or UFT administered using a 21-day consecutive, metronomic-like regimen significantly enhanced the antitumor efficacy, suppressing tumor growth for 2-4 times longer than monotherapy. To investigate the mechanisms by which S-1 enhances the antitumor activity of ANA, the protein and mRNA expression levels of ER-α in tumor tissue after treatment with S-1, ANA, and the typical chemotherapeutic agents doxorubicin (ADM) or paclitaxel (TXL) were analyzed. The protein and mRNA expression levels of ER-α in the tumor tissue were markedly decreased after treatment with S-1 or S-1 + ANA, but not after treatment with either ADM or TXL. The reduced ER-α level after S-1 treatment might contribute to the increased antitumor activity of ANA by reducing ER-α-induced growth signaling in addition to the decrease in estrogen production induced by ANA. Based on these results, the combination of ANA and S-1 might yield a greater benefit than other chemotherapeutic agents in postmenopausal women with ER-positive breast cancer.

Giant mesenchymal hamartoma of the liver in an adult.

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

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

BACKGROUND/AIMS: Nitric oxide synthase 2 (NOS2) is expressed during liver regeneration after a partial hepatectomy (PHx); NOS2 subsequently synthesizes nitric oxide (NO). However, the role of NOS2-synthesized NO in post-PHx liver regeneration remains unclear. We investigated the role of NOS2-synthesized NO in liver regeneration. METHODS: NOS2 knockout (NOS2-KO) mice and control mice were subjected to PHx. Liver mass recovery and serum alanine aminotransferase (ALT) levels were then evaluated. The expressions of Ki-67 and single-strand DNA were also evaluated in remnant liver specimens. Differences in the gene expression profiles of the two groups of remnant liver specimens were analysed using a microarray and were validated using a reverse transcription-polymerase chain reaction (RT-PCR). RESULTS: In NOS2-KO mice, liver regeneration was delayed and apoptosis and serum ALT levels were higher than the levels in the control mice. A microarray study and RT-PCR revealed that heat shock protein 70 family (HSP70 family), haeme oxygenase 1 (Hmox1), neuropilin 1 (Nrp1) and epidermal growth factor receptor (EGFR) were downregulated in NOS2-KO mice. CONCLUSIONS: NOS2-synthesized NO may improve hepatocyte viability through the induction of the HSP70 family and Hmox1 and may sensitize the remnant liver to growth factors through the induction of Nrp1 and EGFR post-PHx.

Six consecutive cases of successful adult ABO-incompatible living donor liver transplantation: a proposal for grading the severity of antibody-mediated rejection.

BACKGROUND: The clinical symptoms, histological findings, and treatments for antibody-mediated rejection (AMR), which is the leading cause of graft loss in adult ABO-incompatible liver transplantation (ABO-I-LT), have rarely been discussed. METHODS: We performed adult living donor ABO-I-LT on six patients. We used anti-CD20 monoclonal antibody combined with plasma exchange preoperatively and intraportal or hepatic-arterial infusion, consisting of prostaglandin E1, corticosteroids, and protease inhibitor postoperatively to prevent AMR. Splenectomy was performed in patients 1, 4, 5 and 6 but not in patients 2 and 3. Weekly liver biopsies were performed after ABO-I-LT. When severe AMR was diagnosed, we performed plasma exchange combined with gamma-globulin bolus infusion (PE+IVIG). RESULTS: In patients 1-3, severe jaundice, rapid decreases in platelet counts, and severe coagulopathy were observed in the early postoperative period. Liver biopsies sampled after the onset of these clinical findings were characterized by severe periportal and lobular hemorrhagic and neutrophil infiltration, suggesting that severe AMR occurred. However, after the initiation of PE+IVIG, AMR was remedied in all three patients. In patients 4-6, severe AMR was not observed. Mild AMR characterized by mild portal hemorrhagic infiltration was observed in patient 4, and moderate AMR characterized by moderate periportal and lobular hemorrhagic infiltration was observed in patient 6. Patients 4-6 did not require PE+IVIG and their clinical course was uneventful. CONCLUSION: Given the experience of these six patients, we consider that AMR may be graded based on liver biopsy findings including hemorrhagic infiltration and neutrophil infiltration, as well as clinical findings. All six patients are currently doing well.

Management of massive arterial hemorrhage after pancreatobiliary surgery: does embolotherapy contribute to successful outcome?

Massive arterial hemorrhage is, although unusual, a life-threatening complication of major pancreatobiliary surgery. Records of 351 patients who underwent major surgery for malignant pancreatobiliary disease were reviewed in this series. Thirteen patients (3.7%) experienced massive hemorrhage after surgery. Complete hemostasis by transcatheter arterial embolization (TAE) or re-laparotomy was achieved in five patients and one patient, respectively. However, 7 of 13 cases ended in fatality, which is a 54% mortality rate. Among six survivors, one underwent selective TAE for a pseudoaneurysm of the right hepatic artery (RHA). Three patients underwent TAE proximal to the proper hepatic artery (PHA): hepatic inflow was maintained by successful TAE of the gastroduodenal artery in two and via a well-developed subphrenic artery in one. One patient had TAE of the celiac axis for a pseudoaneurysm of the splenic artery (SPA), and hepatic inflow was maintained by the arcades around the pancreatic head. One patient who experienced a pseudoaneurysm of the RHA after left hemihepatectomy successfully underwent re-laparotomy, ligation of RHA, and creation of an ileocolic arterioportal shunt. In contrast, four of seven patients with fatal outcomes experienced hepatic infarction following TAE proximal to the PHA or injury of the common hepatic artery during angiography. One patient who underwent a major hepatectomy for hilar bile duct cancer had a recurrent hemorrhage after TAE of the gastroduodenal artery and experienced hepatic failure. In the two patients with a pseudoaneurysm of the SPA or the superior mesenteric artery, an emergency re-laparotomy was required to obtain hemostasis because of worsening clinical status. Selective TAE distal to PHA or in the SPA is usually successful. TAE proximal to PHA must be restricted to cases where collateral hepatic blood flow exists. Otherwise or for a pseudoaneurysm of the superior mesenteric artery, endovascular stenting, temporary creation of an ileocolic arterioportal shunt, or vascular reconstruction by re-laparotomy is an alternative.

Disruption of the middle hepatic vein is not crucial for liver regeneration of the remnant liver after right hemihepatectomy for hepatic tumors.

BACKGROUND: To clarify the role of the middle hepatic vein (MHV) in liver regeneration of the remnant liver after right hemihepatectomy for hepatic tumors, we reviewed 29 patients to evaluate liver regeneration for up to 12 postoperative months. METHODS: Volume regeneration of the remnant liver was investigated by computed tomography at 3, 6, and 12 postoperative months. The remnant liver was divided into the following three areas: the medial section (segment IV), the lateral section (segments II and III), and segment I. The patients were divided into two groups: group A (n = 17), in which the MHV was preserved in the remnant liver, and group B (n = 12), in which the MHV was removed. RESULTS: Volume regeneration of each area continued until 6 postoperative months but did not increase thereafter. On univariate analysis, differences in the volume regeneration of each area between the groups were not significant at any measured time point. Furthermore, disruption of the MHV was determined to not be crucial to the volume regeneration of any liver area on multivariate analysis. Only the resection volume (percentage) significantly affected liver regeneration of the remnant liver. CONCLUSIONS: Disruption of the MHV does not decisively affect liver regeneration of remnant liver after right hemihepatectomy for hepatic tumors.

Applicability of the Milan criteria for determining liver transplantation as a first-line treatment for hepatocellular carcinoma.

BACKGROUND: To determine whether or not the Milan criteria (MC) should be used to determine the applicability of liver transplantation (LT) as a first-line treatment for patients with cirrhosis with hepatocellular carcinoma (HCC) who are able to endure hepatectomy. METHODS: Retrospective analysis of 82 patients with cirrhosis with HCC who were treated by hepatectomy without LT at our institution between 1990 and 2003. RESULTS: Of these 82 patients, 48 met the MC. Proportional hazard regression analyses to determine the independent prognostic factors for postoperative cumulative patient and disease-free survival showed that meeting the MC is the strongest prognostic factor for both patient and disease-free survival. The cumulative patient and disease-free survival rates were 76.7% and 28.9%, respectively, at 5 years in patients who met the MC. The cumulative disease-free survival was markedly inferior to those in previously reported series of LT for HCC who met the MC, but the cumulative patient survival was comparable to those in the previously reported series. A comparison of cumulative postoperative survival between patients who met the MC and fulfilled all five factors listed below and patients who met the MC but did not fulfill any of the five factors demonstrated that the latter patients showed statistically significantly worse postoperative patient survival than the former. The five factors included: Model for End-Stage Liver Disease score < 10, indocyanine green retention rate at 15 minutes < 20%, absence of microscopic fibrous capsular invasion and microscopic intrahepatic metastases, and earlier grade (T1 or T2) of American Joint Committee on Cancer tumor classification. CONCLUSIONS: The MC should not be used to determine the applicability of LT as a first-line treatment for patients with HCC considered able to endure hepatectomy. However, modifying MC with some clinicopathological factors could satisfy the appropriate criteria for applying LT as a first-line treatment for these patients.

[Standard surgery as part of the multidisciplinary treatment for pancreatic cancer].

Standardization of surgical procedure for pancreatic cancer has been recognized to be necessary and important these days. Recent studies appear to exhibit efficacy of the adjuvant chemoradiation therapy before or after pancreatic surgery. In this study, we examined the standard surgery as part of the multidisciplinary treatment for pancreatic cancer. Invasive ductal carcinoma of the pancreas was resected in 121 patients in our institution from 1992 through 2005. We stopped performing an extended lymphadenectomy with pancreatectomy in 2003, but the survival rates were not significantly different between the cases before and after 2003. We usually resect half of the nerve plexus around the superior mesenteric artery (SMA) as a standard procedure. When we achieved the microscopically curative resection (R0) even if the plexus around SMA or the portal vein was invaded, there were a few long survivors for more than five years. The R0 resection is the most important factor for prolonged survival. Pancreatectomy including removal of regional lymph nodes (D2) and half of the nerve plexus around SMA and combined resection of the infiltrated portal vein is thought to be a standard surgery from the viewpoint of decrease in morbidity and maintenance of curability.

Safety limit of the extent of hepatectomy for rats with moderately fatty liver: experimental study concerning living liver donor safety.

INTRODUCTION: The aim of the present study was to determine whether rats with moderately fatty liver could withstand a 90% hepatectomy, which rats with normal livers can survive. MATERIAL AND METHODS: Nine-week-old male Wistar rats were used. Normal rat chow was fed to the normal liver group, and fat-enriched rat chow was fed to the fatty liver group for 4 weeks to induce a moderately fatty liver. The authors have previously reported that this fatty liver rat model can cause fatal liver dysfunction after reduced-size-liver transplantation. A 90% and 95% hepatectomy were performed using rats of both groups to evaluate posthepatectomized liver function. RESULTS: All rats undergoing a 90% hepatectomy were still alive 30 days after the hepatectomy, but the rats that underwent a 95% hepatectomy were all dead within 4 days regardless of group. Increases in the liver remnant wet weight measured until 7 postoperative days after 90% hepatectomy were almost similar among the two groups. Alanin aminotransferase measured at 24, 48, 72, and 168 h after a 90% hepatectomy were significantly higher in the fatty liver group than in the normal liver group. Similarly, at up to 72 h postoperatively, the serum hyarulonic acids were significantly higher in the fatty liver group. CONCLUSION: A moderately fatty liver did not cause mortality in 90% hepatectomized rats. However, it caused a higher degree of hepatic parenchymal as well as sinusoidal injury.

A rat model of a repeat 70% major hepatectomy.

BACKGROUND: This study investigated the effects of a repeat 70% major hepatectomy in a rat model. MATERIALS AND METHODS: The left lateral and median lobes of the livers of 80 seven-week-old male Wistar rats were excised during primary hepatectomy, removing a total of 70% of the liver. In 40 of the rats, the regenerated right lateral lobe, comprising 70% of the remnant liver, was excised during secondary hepatectomy 7 days after the initial procedure. The survival rate, posthepatectomized regeneration ratio, and laboratory blood data were compared between the groups that had undergone initial only and repeat hepatectomies. RESULTS: All of the rats survived for at least 7 days after each procedure. The remaining liver returned to up to about 90% of its original wet weight by 5 days in both groups. The serum glutamic-pyruvic transaminase levels peaked 12 h after hepatectomy, remained at a similar level at 36 h, and had normalized by 2 days. Serum total bilirubin levels were similar in both groups. The total cell numbers after 5 days were significantly higher in the initial hepatectomy group than in the repeat hepatectomy group. CONCLUSIONS: We established a rat model in which an initial 70% major hepatectomy was followed by a repeat 70% major hepatectomy of the regenerated liver. The time taken to restore the integrity of the liver was longer in the rats that underwent repeat hepatectomy. We believe that this model will be useful for investigating the regenerative ability of the liver after a second major hepatectomy.

Transcription factors and drug resistance.

Intrinsic or acquired resistance to anticancer agents is a major obstacle to the success of chemotherapy. Anticancer agents are known to modulate signal transduction pathways and alter expression of genes that play an important role in drug resistance. Emerging evidence suggests that the complexity of genomic response against anticancer agents arise from elaborate gene expression by multiple transcription factors. Here, we briefly describe the development of solid tumours and the appearance of drug-resistant cells. We also review what is known of the transcription factors that are involved in resistance to drugs, particularly cisplatin.

Pharmacologic preconditioning effects: prostaglandin E1 induces heat-shock proteins immediately after ischemia/reperfusion of the mouse liver.

Prostaglandin E1 (PGE1) has several potential therapeutic effects, including cytoprotection, vasodilation, and inhibition of platelet aggregation. This study investigates the protective action of PGE1 against hepatic ischemia/reperfusion injury in vivo using a complementary DNA microarray. PGE1 or saline was continuously administered intravenously to mice in which the left lobe of the liver was made ischemic for 30 minutes and then reperfused. Livers were harvested 0, 10, and 30 minutes postreperfusion. Messenger RNA was extracted, and the samples were labeled with two different fluorescent dyes and hybridized to the RIKEN set of 18,816 full-length enriched mouse complementary DNA microarrays. Serum alanine aminotransferase and aspartate aminotransferase levels at 180 minutes postreperfusion were significantly lower in the PGE1-treated group than in the saline-treated group. The cDNA microarray analysis revealed that the genes encoding heat-shock protein (HSP) 70, glucose-regulated protein 78, HSP86, and glutathione S-transferase were upregulated at the end of the ischemic period (0 minutes postreperfusion) in the PGE1 group. Our results suggested that PGE1 induces HSPs immediately after ischemia reperfusion. HSPs might therefore play an important role in the protective effects of PGE1 against ischemia/reperfusion injury of the liver.

Primary malignant peripheral nerve-sheath tumor of the common bile duct.

Primary malignant peripheral nerve-sheath tumors of the common bile duct are extremely rare. To our knowledge, the published literature contains no previous case report of this disease. Here we report on a 58-year-old Japanese woman with a primary malignant peripheral nerve-sheath tumor of the common bile duct, which was completely resected. A hypoechoic mass was identified in the hepatic hilus, using ultrasonography and computed tomography. Endoscopic retrograde cholangiography revealed a smooth stricture and deviation of the common bile duct. Laparotomy exposed a firm mass around the common bile duct that had not invaded the surrounding tissues. Partial resection of the common bile duct and cholecystectomy were performed as the treatment of choice. The final histopathological diagnosis was malignant peripheral nerve-sheath tumor arising from the wall of the common bile duct.

Middle hepatic vein tributary reconstruction could not act as a complete substitute for an entirely preserved middle hepatic vein.

BACKGROUND/AIMS: The necessity of the middle hepatic vein for living donor liver transplantation using right lobe graft is still controversial. METHODOLOGY: We reviewed 7 long-term surviving right-lobe recipients in whom middle hepatic vein tributaries were not reconstructed (group A, n=4) or were reconstructed (group B, n=3). Volume regeneration of the right paramedian (segments V+VIII) and right lateral (segments VI+VII) sectors was assessed by computed tomography at 3, 6, 9, and 12 postoperative months. The right paramedian sector was further subdivided into the ventral portion in relation to the anterior branch of the right portal vein and dorsal portion. RESULTS: The volume regeneration ratio was significantly lower in group A than in group B persistently after 6 postoperative months in regard to the right paramedian sector, the dorsal portion, and especially the ventral portion (0.64 +/- 0.19 vs. 1.22 +/- 0.17, p=0.034, 12 postoperative months). However, volume regeneration was impaired in the ventral portion as compared to other areas in group B. CONCLUSIONS: In conclusion, middle hepatic vein tributary reconstruction improves the volume regeneration of the right paramedian sector in right lobe living donor liver transplantation However, it could not act as a complete substitute for an entirely preserved middle hepatic vein.

DNA topoisomerase II poison TAS-103 transactivates GC-box-dependent transcription via acetylation of Sp1.

Drug-induced modifications of transcription factors play important roles in both apoptosis and survival signaling. The data presented here show that the DNA topoisomerase II poison TAS-103 transactivated the SV40 promoter in a GC-box-dependent manner and induced Sp1 acetylation in cells expressing p300. This activity was not observed in cells lacking p300. TAS-103 treatment also enhanced the p300 content of the nucleus and the interaction of p300 with Sp1. Cellular susceptibility to TAS-103 was correlated with p300 expression but not with topoisomerase II expression. Furthermore, the presence of p300 significantly sensitized cancer cells to TAS-103 but not to cisplatin. Taken together, these findings demonstrate novel genomic responses to anticancer agents that modulate Sp1 acetylation and Sp1-dependent transcription in an apoptotic pathway.

Surgical strategy for the management of biliary injury in laparoscopic cholecystectomy.

BACKGROUND/AIMS: The incidence of biliary injury during laparoscopic cholecystectomy remains high and several complications resulting from injuries have recently been reported. The aim of this study is to elucidate the surgical strategy for the management of biliary injury during laparoscopic cholecystectomy. METHODOLOGY: Ten patients with biliary injury during laparoscopic cholecystectomy are retrospectively reviewed. RESULTS: Second operations as initial repair were performed in five patients in our institute. Duct-to-duct anastomosis for one and duct-enterostomies for two were performed in three common bile duct transections. Simple closures were performed for the other two biliary injuries. Another five cases underwent both laparoscopic cholecystectomies and second operations for initial repair when they were referred to our service. Four were treated by a third operation in our institution including hilar bile duct resections and duct-enterostomies in two, and right hepatic lobectomies in the other two cases. The last patient could not be treated because of his poor condition and he died of hepatic failure soon after the consultation. CONCLUSIONS: Complications resulting from biliary injury have recently been reported, necessitating liver transplantation. Laparoscopic surgeons should avoid biliary injury and must not perform inadequate biliary reconstruction, which leads to secondary biliary cirrhosis, cholangitis, liver failure, and finally patient death.

Prognostic significance of UDP-N-acetyl-alpha-D-galactosamine:polypeptide N-acetylgalactosaminyltransferase-3 (GalNAc-T3) expression in patients with gastric carcinoma.

Aberrant glycosylation occurs during development of gastric carcinomas. The initiation of mucin-type O-glycosylation is regulated by GalNAc-T3 (UDP-N-acetylgalactosamine:polypeptide N-acetylgalactosaminyltransferase-3). However, the clinical significance of GalNAc-T3 expression in human gastric carcinoma has not yet been demonstrated. In the present study, we investigated the relationship between immunohistochemical GalNAc-T3 expression and various clinicopathologic factors, including prognosis, in 117 gastric carcinoma patients. Of 117 gastric carcinomas examined, 59 (50.4%) showed strong expression of GalNAc-T3. Strong expression was detected in 38 of 59 (64.4%) differentiated type and in 21 of 58 (36.2%) undifferentiated gastric carcinomas, indicating that the expression of GalNAc-T3 correlated significantly with tumor differentiation (P=0.0023, chi2 test). Overall 5-year survival rate in patients with strong GalNAc-T3 expression (71.0%) was significantly better than that of patients with weak expression (49.3%) (P=0.0197, log-rank test). Multivariate analysis identified GalNAc-T3 expression as an independent prognostic factor (P=0.0158, Cox proportional hazards model). Our data suggest that GalNAc-T3 expression may be a useful marker for prognosis and differentiation of gastric carcinomas.