Gene expression of ATP-binding cassette transporters during liver regeneration after 90% hepatectomy in rats.

Liver damage with hyperbilirubinemia during regeneration of the small liver is the major hurdle to expand the indications of adult living donor liver transplantation. We performed a large-scale gene expression analysis of the regenerating liver after a 90% hepatectomy in rats, and analyzed the changes in the gene expression patterns related to the ATP-binding cassette (ABC) transporters. RNAs were prepared from 3 rat livers at 0, 24, 72 and 168 h after a 90% hepatectomy. The gene expression profile was analyzed by the Rat Genome 230 2.0 array with special references to the ABC transporters. Among 31,042 probes, 1,587 reported genes were identified as either upregulated or downregulated more than 2-fold. Among 20 ABC transporter genes, multidrug resistance protein (MRP) 2 and organic anion transporting polypeptide (OATP) 1 were significantly downregulated, while MRP1 and MRP3 tended to be expressed. These genetic changes were confirmed by real-time PCR. A microarray analysis demonstrated not only an extensive gene expression profile in the regenerating liver but more specific molecular events related to bilirubin transport at the same time. Changes in the expression pattern of the ABC transporters, therefore, seem to be the key event in liver failure during liver regeneration.

Surgical management of colorectal cancer in patients with psychiatric disorders.

PURPOSE: We analyzed the surgical data and evaluated the management of colorectal cancer (CRC) in patients with psychiatric disorders. METHODS: We reviewed the medical records of 83 patients who underwent elective surgery for CRC and divided them into a psychiatric disorder group and a control group to compare the operative data and available clinical information. RESULTS: Of the 83 patients, 27 had psychiatric disorders. The most characteristic symptom of CRC was bloody stool in the psychiatric disorder group, and occult blood in the control group. Postoperative pneumonia occurred significantly more often in the psychiatric group (14.8% vs 1.8%, P = 0.019). Patients with a psychiatric disorder needed significantly more psychotropic drugs (70.4% vs 7.1%, P < 0.001), more physical restraint (44.4% vs 12.5%, P = 0.001), and exhibited more resistant behavior (51.9% vs 8.9%, P < 0.001) postoperatively than the controls. Moreover, a significant decrease in serum albumin (Alb) and total protein (TP) was seen in the psychiatric disorder group on postoperative days (PODs) 21 and 28. A psychiatric disorder was a significant predictive factor for a decrease in TP (odds ratio [OR] 24.2) and Alb (OR 8.6). CONCLUSIONS: Insufficient nutrition in the psychiatric disorder group was not attributable solely to the higher incidence of postoperative complications. As psychiatric disorders compromise nutrition, integral treatment provided by surgeons and psychiatrists would improve the nutritional status of these patients and reduce the incidence of postoperative morbidity.

Torsion of an accessory lobe of the liver in a child: report of a case.

We report a case of torsion of an accessory lobe of the liver (ALL) in a 14-year-old girl. The patient was admitted for acute abdominal pain and laparotomy revealed an ALL, the pedicle of which was elongated with 180 degrees torsion. The diagnosis was not made preoperatively because of the rarity of this condition. However, a close relationship between omphalocele repair and the development of ALL has been reported; thus, a history of omphalocele repair should alert the doctor to the possibility of this condition, which could be suggested by imaging findings preoperatively. Torsion of an ALL should be included in the differential diagnosis of a patient with a history of omphalocele, who presents with acute abdominal symptoms.

Characterization of heparan sulfate on hepatocytes in regenerating rat liver.

BACKGROUND/PURPOSE: Liver regeneration occurs through interactions between the receptors on hepatocytes, including proteoglycans (PGs) and glycosaminoglycans (GAGs), and various growth factors. We investigated serial changes in GAGs, particularly heparan sulfate (HS), in proliferating hepatocytes. METHODS: We performed 70% hepatectomy in male Wistar rats, and we then isolated hepatocytes by a collagenase perfusion method after each surgery. DNA synthesis was evaluated by measuring proliferating cell nuclear antigen (PCNA). After we had treated the hepatocytes by delipidation and digestion with actinase E, endo-beta-xylosidase, and alpha-amylase, we quantified GAGs by a carbazole-sulfuric acid method. GAGs were analyzed by ion-exchange chromatography, and changes in molecular weight of the HS component were investigated by size-fractionation HPLC. RESULTS: Hepatocyte mitosis peaked at 24 h after the amount of GAGs was increased at 24 and 72 h after surgery. The amount of HS was slightly increased at 3 to 12 h after surgery, and then peaked at 24 h. The molecular weight of the HS declined by 12 h, but had recovered to the preoperative level by 24 h. CONCLUSIONS: These results suggested that this HS molecule, which contained about ten disaccharide units during proliferation, may be an initiator of hepatocyte proliferation.

Biliary hemorrhage after removal of an expandable metallic stent during liver transplantation.

The self-expandable metallic stent (SEMS) has become a common device for palliative treatment of malignant biliary obstructions or benign strictures. Despite the ease of placement of SEMSs, their removal has been reported to be very difficult. Here, we report a case with primary sclerosing cholangitis who developed massive hemorrhage after intraoperative removal of a SEMS. Possible living donor liver transplantation (LT) was considered for a 49-year-old female with primary sclerosing cholangitis. However, her general condition did not meet the criteria for LT; therefore, she was referred back to her primary physician. Two years later, she developed jaundice, and her primary physician placed multiple SEMSs, 1 of which was placed across the papilla of Vater. She was evaluated rapidly, and underwent living donor LT. During the operation, the common bile duct was examined and an incision was made. A stent was found firmly embedded in the bile duct. Each wire of the SEMS was pinched and then successfully pulled out 1 by 1. Finally, all parts of the SEMS were removed. Before creating the Roux-en-Y limb, hemorrhage from the remnant bile duct was confirmed by examination of the duodenum and bile duct stump. The bile duct was sewn internally with monofilament stitches and compressed for 10 minutes. Finally, hemostasis was brought about and transplantation was completed successfully. Despite some reports regarding successful endoscopic removal of SEMSs, its removal in patients with portal hypertension coagulopathy is risky. SEMSs should not be placed in patients who are candidates for LT.

A bioartificial liver that combines plasma dialysis and whole liver perfusion.

BACKGROUND/AIMS: The development of a bioartificial liver with xenogeneic hepatocytes requires sufficient hepatocyte mass for metabolic support, decreased immunogenicity, and prevention of viral transmission. Therefore, the authors developed a plasma dialysis system using a selective plasma filter, and combined this dialysis system with whole liver plasma perfusion (PDWLP). In this system, the patient's plasma was dialyzed with normal plasma recycled through the pig liver. METHODOLOGY: Female inbred Large White pigs were used for the hepatic failure model and for liver donation. Fulminant hepatic failure (FHF) was induced by the intraportal administration of alpha-amanitin and lipopolysaccharide. Nine hours after this injection, the FHF pigs were connected to the dialysis system for 6 h (n = 5). Control FHF pigs were not connected to the dialysis system (n = 10). RESULTS: Animal survival was lengthened, and cardiovascular stability was demonstrated in the PDWLP treated pigs. This system suppressed the production of substances that promote encephalopathy. The liver necrosis and neutrophil infiltration were significantly less in the experimental pigs. CONCLUSIONS: The experimental treatment attenuated the progression of FHF. Extracorporeal liver, perfused with oxygenated plasma, functioned for 6 h without hyperacute rejection. This type of hybrid bioartificial liver may be useful for treating FHF patients.

Plasma exchange-based plasma recycling dialysis system as an artificial liver support.

We developed a plasma recycling dialysis (PRD) system based on plasma exchange (PE). In this system, rapid reduction of toxic substances and restitution of deficient essential substances are performed by PE and subsequent blood purification is performed by dialysis between separated plasma recycled over a purification device and the patient's blood across the membrane of a plasma separator. To demonstrate the safety and efficacy of this system, we used a pig model of fulminant hepatic failure (FHF) and anion exchange resin, activated charcoal and hemodialysis for the purification device. FHF was induced by intraportal administration of alpha-amanitine (0.1 mg/kg) and lipopolysaccharides (1 microg/kg) in pigs. Three groups of animals were studied: group 1, diseased controls (N = 4); group 2, PE group (N = 4), 16 h after drug infusion the pigs underwent PE of approximately 1.2 L for 2 h; and group 3, PE + PRD group (N = 4), the pigs underwent PE followed by PRD for 6 h. The hemodynamic status of all animals was stable during the procedure. In group 3, the values of ammonia, total bile acid and total bilirubin continuously decreased and were significantly lower than those of the animals in group 2 24 h after the induction of FHF. The Fischer ratio was significantly higher than in group 2 after 24 h. Group 3 pigs maintained a higher level of consciousness and survived longer than group 2 pigs. Safety of this PE-based PRD system was demonstrated and the removal of toxic substances was significant. This study confirmed the clinical utility of this system as an artificial liver support.

Establishment of transplantable murine osteosarcoma cell line with endochondral ossification.

Osteosarcoma is defined as a malignant mesenchymal tumor in which tumor cells produce bone matrix. Osteosarcoma cell line (Nishi-Hirosaki osteosarcoma, NHOS) from a spontaneous soft tissue tumor in an athymic mouse was established. The cultured NHOS cells formed a monolayer consisting of spindle to polygonal cells without extracellular matrix formation or mineralization. In contrast, the transplanted NHOS tumor in immunodeficient mice consisted of short spindle and pleomorphic cells, associated with networks of calcified bone and osteoid matrices, as well as small foci of chondroid matrix. Pulmonary metastasis was detected in 22 (42.3%) out of the 52 tumor-bearing mice when NHOS cells were transplanted into the murine flanks. Pulmonary metastasis was detected in all mice (6/6) at post-injection days 21-49 when the cells were injected into the murine tail veins. The NHOS transplantable osteosarcoma cell line with ossifying ability would be useful to clarify the mechanisms of aggressive metastatic potential, as well as for studying the ossification process involved in cell-to-matrix interactions.

Resection of a locally advanced hilar tumor and the hepatic artery after stepwise hepatic arterial embolization: a case report.

We herein report a case of a hilar tumor with extensive invasion to the proper hepatic artery, which was successfully treated with a radical resection in a 57-year-old female patient after a stepwise hepatic arterial embolization. She underwent right colectomy and partial hepatectomy for advanced colon cancer two years ago and radiofrequency ablation therapy for a liver metastasis one year ago, respectively. A recurrent tumor was noted around the proper hepatic artery with invasion to the left hepatic duct and right hepatic artery 7 mo previously. We planned a radical resection for the patient 5 mo after the absence of tumor progression was confirmed while he was undergoing chemotherapy. To avoid surgery-related liver failure, we tried to promote the formation of collateral hepatic arteries after stepwise arterial embolization of the posterior and anterior hepatic arteries two weeks apart. Finally, the proper hepatic artery was occluded after formation of collateral flow from the inferior phrenic and superior mesenteric arteries was confirmed. One month later, a left hepatectomy with hepatic arterial resection was successfully performed without any major complications.

Decreased postprandial gallbladder emptying in patients with black pigment stones.

AIM: To analyze gallbladder contractility in patients with black pigment stones (BPSs) and to compare this with patients with cholesterol stones (CSs) and healthy volunteers. METHODS: The pattern of bile evacuation from the gallbladder was quantified by computer cholescintigraphy in 28 normal subjects, 22 patients with CSs and 14 with BPSs. The parameters of gallbladder contractility included ejection period (EP), ejection fraction (EF) and ejection rate (ER). RESULTS: A significantly shorter EP was observed in patients with BPSs in comparison to those with CSs (t = 2.4, P < 0.05). EF in BPS patients significantly decreased in comparison to that in CS and normal subjects (t = 6.4, P < 0.0001; t = 2.1, P < 0.05). EF in CS patients also significantly decreased in comparison to that in normal subjects (t = -3.0, P < 0.005). Consequently, ER in patients with BPSs and CSs was significantly smaller than that in normal subjects (t = 3.1, P < 0.005; t = -3.5, P < 0.001). Moreover, in cases where postprandial reflux of a radioisotope into the common hepatic duct from the gallbladder was observed, EF and ER of either CS or BPS patients showed a significant reduction. CONCLUSION: Bile evacuation from the gallbladder is reduced in patients with BPSs, in comparison to those with CSs and to healthy volunteers. Bile stagnation due to impaired gallbladder kinetics seems to be one of the predisposing factors for the development of BPSs.

A case of invasive hemolymphangioma of the pancreas.

Hemolymphangioma of the pancreas is a very rare benign tumor. There were only five reports of this disease until March 2008. Herein, we report a case of hemolymphangioma of the pancreas with gastrointestinal bleeding due to duodenal invasion. A 53-year-old man had been admitted a referral hospital because of severe anemia due to gastrointestinal bleeding in December 2005. He was then transferred to our institute with a diagnosis of a tumor of the head of the pancreas with duodenal invasion in January 2006. No abnormalities were revealed except for anemia in laboratory data including CEA and CA19-9. Gastrointestinal endoscopy revealed bleeding at the duodenum. Computed tomography also demonstrated a heterogenous mass at the pancreatic head and suspected invasion to the duodenal wall. Ultrasonography showed a huge mass at the pancreatic head with a mixture of high and low echoic areas. Pylorous-preserving pancreatoduodenectomy was performed. The pancreatic tumor was soft and had invaded to the duodenum. The pathological diagnosis was a hemolymphangioma of the pancreas invaded to the duodenum. His postoperative course was uneventful and he was discharged on the 26th d after surgery. Hemolymphangioma of the pancreas is a very rare benign tumor. In a literature review until March 2008, we found five case reports. Major symptoms are abdominal pain and distension due to the enlarged tumor. However, we experienced a case of hemolymphangioma of the pancreas with gastrointestinal bleeding due to invasion to the duodenum. This disease is a very rare entity, but should be considered when patients have gastrointestinal bleeding.

Immunohistochemical study on liver fibrosis in biliary atresia.

BACKGROUND/AIMS: Although advanced liver fibrosis is a critical complication in influencing the outcome of biliary atresia (BA), the mechanism is poorly understood. In adult hepatic disorders, the relationships between sinusoidal liver cells (SLC) such as hepatic stellate cells (HSCs), some growth factors and enzymes concerned with extracellular matrix (ECM) metabolism have been clarified, but are unknown in BA. This study aimed to investigate such relationships in BA. METHODOLOGY: Seventeen liver samples from 14 patients with BA were immunohistochemically examined using primary antibodies such as alpha smooth muscle actin (alphaSMA), transforming growth factor beta (TGFbeta), platelet-derived growth factor (PDGF), matrix metalloproteinase (MMP)-1, MMP-2, tissue inhibitors of metalloproteinase (TIMP)-1 and TIMP-2. The degree of liver fibrosis and these immunohistochemical findings were compared and examined semiquantitatively. Ultrathin sections from two samples were also examined with electron microscopy. RESULTS: The immunoreactivity of alphaSMA and MMPs increased with the degree of liver fibrosis, whereas that of TGFbeta, PDGF, and TIMPs showed no difference in expression in groups with any degrees of fibrosis. The immunoreactivity of MMPs statistically significantly increased in fibrotic livers. Electronmicroscopically, HSCs had many filaments in their cytoplasm, showing myofibroblastic morphology. CONCLUSIONS: The present study gave a different result than other reports on adult liver fibrosis. Livers with BA may be in a predominant state of fibrolysis, indicating the presence of the similar process to recovery from liver fibrosis in adults.

Decreased expression of claudin-1 is correlated with recurrence status in esophageal squamous cell carcinoma.

Claudins are transmembrane proteins and major constitutes of tight junctions, and participate in the paracellular barrior and cellular connecting functions. They have been shown to be differentially regulated in malignant tumors and play a role in carcinogenesis and tumor progression. Recent studies have shown changes in expression of claudins during tumorigenesis. However, a causal relationship between claudin expression and cancer recurrent status has not been established. In this study, we examined 54 esophageal cancer cases to assess immunohistochemical expression patterns of claudin-1. Eleven (20.4%) of 54 cases had negative immunostaining for claudin-1. Decreased expression of claudin-1 was statistically correlated with recurrence status (P = 0.018). The cases with lymphatic vessel permeation showed reduced expression patterns of claudin-1 (P = 0.033). Decreased expression of claudin-1 was also correlated with short diseasefree survival (P = 0.0003) and overall survival (P = 0.0045). The results indicated that claudin-1 expression was correlated with the recurrence status and poor prognosis in esophageal cancer and claudin-1 expression may be a good indicator of recurrence in esophageal cancer.

Effects of proteoglycan on dextran sulfate sodium-induced experimental colitis in rats.

Proteoglycans (PG) are macromolecules composed of glycosaminoglycan chains covalently attached to a protein core. In this study, we examined the effects of PG on dextran sulfate sodium (DSS)-induced experimental colitis in rats. First, to examine whether PG may ameliorate acute established DSS colitis, PG was administered orally for 5 days to the model animals. We evaluated the effects of PG on the basis of clinical symptoms, hematological analysis, macroscopic observation, and microscopic examination. We then examined whether PG administered orally to rats was detectable in their colonic lumen. After administration of PG, the colonic contents were collected, and the molecular weight of PG in the sample was analyzed by gel filtration high-performance liquid chromatography. Furthermore, we examined whether orally administered PG affected the concentrations of short-chain fatty acids (SCFAs) in the colonic feces. Orally administered PG ameliorated the clinical symptoms of bloody stools and diarrhea, and attenuated the increase in the white blood cell count in rats with established DSS colitis. Histologically, orally administered PG reduced the degree of mucosal erosion and inflammatory cell infiltration into the erosive area induced by DSS. Orally administered PG was detected in rat colon, although its molecular weight was slightly decreased. Orally administered PG significantly increased the concentration of total SCFAs and n-butyrate in rat colonic feces. This is the first study to indicate that exogenous PG ameliorates experimental colitis, suggesting the potential usefulness of PG for clinical treatment of colitis.

Hemosuccus pancreaticus: problems and pitfalls in diagnosis and treatment.

Hemosuccus pancreaticus is a rare cause of intermittent upper gastrointestinal bleeding. We report two cases of hemosuccus pancreaticus with multiple episodes of upper gastrointestinal bleeding. The causes of hemorrhage were rupture of pseudoaneurysm of the splenic artery and bleeding from the wall of pancreatic pseudocyst. Interventional radiology is the first modality for early diagnosis and possible treatment of hemosuccus pancreaticus. When angiography shows no abnormal findings or interventional radiological therapy can not be successful, surgery should be considered without delay. Our patients herein underwent surgery without recurrence or sequelae. Intraoperative ultrasonography and pancreatoscopy were helpful modalities for confirming the source of hemorrhage and determining the cutting line of the pancreas. When we encounter intermittent upper gastrointestinal bleeding with an obscure source, hemosuccus pancreaticus should be included in differential diagnoses especially in patients with chronic pancreatitis, which would lead to a prompt and proper treatment.

Intraoperative ultrasound as an educational guide for laparoscopic biliary surgery.

AIM: To analyze the efficacy of routine intraoperative ultrasound (IOUS) as a guide for understanding biliary tract anatomy, to avoid bile duct injury (BDI) after laparoscopic cholecystectomy (LC), as well as any burden during the learning period. METHODS: A retrospective analysis was performed using 644 consecutive patients who underwent LC from 1991 to 2006. An educational program with the use of IOUS as an operative guide has been used in 276 cases since 1998. RESULTS: IOUS was highly feasible even in patients with high-grade cholecystitis. No BDI was observed after the introduction of the educational program, despite 72% of operations being performed by inexperienced surgeons. Incidences of other morbidity, mortality, and late complications were comparable before and after the introduction of routine IOUS. However, the operation time was significantly extended after the educational program began (P < 0.001), and the grade of laparoscopic cholecystitis (P = 0.002), use of IOUS (P = 0.01), and the experience of the surgeons (P = 0.05) were significant factors for extending the length of operation. CONCLUSION: IOUS during LC was found to be a highly feasible modality, which provided accurate, real-time information about the biliary structures. The educational program using IOUS is expected to minimize the incidence of BDI following LC, especially when performed by less-skilled surgeons.

Des-gamma-carboxy prothrombin as an important prognostic indicator in patients with small hepatocellular carcinoma.

AIM: To clarify the effect of a high des-gamma-carboxy prothrombin (DCP) level on the invasiveness and prognosis of small hepatocellular carcinoma. METHODS: Among 142 consecutive patients with known DCP levels, who underwent hepatectomy because of hepatocellular carcinoma, 85 patients met the criteria for small hepatocellular carcinoma, i.e. oneor=400 mAU/mL (P=0.02) were independent prognostic factors. In the group of patients who met the criteria for small hepatocellular carcinoma, DCP>or=400 mAU/mL was found to be an independent prognostic factor for recurrence-free (P=0.02) and overall survival (P=0.0005). In patients who did not meet the criteria, the presence of vascular invasion was an independent factor for recurrence-free (P=0.02) and overall survivals (P=0.01). In 75% of patients with small hepatocellular carcinoma and high DCP levels, recurrence occurred extrahepatically. CONCLUSION: For small hepatocellular carcinoma, a high preoperative DCP level appears indicative for tumor recurrence. Because many patients with a high preoperative DCP level develop extrahepatic recurrence, it is necessary to screen the whole body.

An easier method for performing a pancreaticojejunostomy for the soft pancreas using a fast-absorbable suture.

AIM: To clarify the usefulness of a new method for performing a pancreaticojejunostomy by using a fast-absorbable suture material irradiated polyglactin 910, and a temporary stent tube for a narrow pancreatic duct with a soft pancreatic texture. METHODS: Among 63 consecutive patients with soft pancreas undergoing a pancreaticoduodenectomy from 2003 to 2006, 35 patients were treated with a new reconstructive method. Briefly, after the pancreatic transaction, a stent tube was inserted into the lumen of the pancreatic duct and ligated with it by a fast-absorbable suture. Another tip of the stent tube was introduced into the intestinal lumen at the jejunal limb, where a purse-string suture was made by another fast-absorbable suture to roughly fix the tube. The pancreaticojejunostomy was completed by ligating two fast-absorbable sutures to approximate the ductal end and the jejunal mucosa, and by adding a rough anastomosis between the pancreatic parenchyma and the seromuscular layer of the jejunum. The initial surgical results with this method were retrospectively compared with those of the 28 patients treated with conventional duct-to-mucosa anastomosis. RESULTS: The incidences of postoperative morbidity including pancreatic fistula were comparable between the two groups (new; 3%-17% vs conventional; 7%-14% according to the definitions). There was no mortality and re-admission. Late complications were also rarely seen. CONCLUSION: A pancreaticojejunostomy using an irradiated polyglactin 910 suture material and a temporary stent is easy to perform and is feasible even in cases with a narrow pancreatic duct and a normal soft pancreas.

[A case of metastasis to the diaphragm from ascending colon cancer].

We reported a case of metastatic tumor to the diaphragm discovered by rising CEA after operation of ascending colon cancer. A 72-year-old female underwent right hemicolectomy on January 2005. After discharge, she received adjuvant chemotherapy by S-1, but a rise of CEA was shown. Based on exploratory findings, laparotomy was done with the diagnosis of metastasis to the liver(S7). A tumor was present in the right diaphragm, and contacted the liver(S7). Partial resection of the right diaphragm was performed. The removed specimen revealed the same histological findings of the last operated ascending colon. Metastasis to the diaphragm is very rare, especially a solitary one as in this case. Etiologically speaking, the tumor cells might be absorbed or have strayed into peritoneal stomata of the diaphragm.

Influence of cancer-related gene polymorphisms on clinicopathological features in colorectal cancer.

BACKGROUND AND AIM: Single nucleotide polymorphisms (SNP) are shown to be related with cancer incidence. It has been reported that CCND1, p21(cip1)DCC, MTHFR, and EXO1 are related with the risk of malignant neoplasm, but few studies have mentioned the prognosis of the patients. We investigated the SNP of patients and related this to clinicopathological features, including survival rate. METHOD: DNA from the tissues of primary colorectal cancer was obtained from surgical resections of 114 patients (68 males and 46 females, 29-83 years). The CCND1 polymorphism was analyzed by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) and those of other genes were investigated by the TaqMan method. The polymorphisms obtained were statistically analyzed for the relationship with clinicopathological features. RESULTS: The CG + GG allele was more invasive than the CC allele in histological tumor depth in the DCC codon 201 (P = 0.0086). The 677TT allele in MTHFR had a larger tumor size than the 677CC allele (P = 0.028). In EXO1 P757L polymorphism, patients with the TT allele had a statistically reduced survival rate compared with the other alleles. In CCND1 polymorphisms, we found no statistical significance in clinicopathological features. CONCLUSIONS: From these preliminary data, these polymorphisms would be candidates predicting the clinicopathological features of colorectal cancer, but further more systematic gene analyses are warranted.