Malignant pheochromocytoma: Hepatectomy for liver metastases.

Malignant pheochromocytoma accounts for approximately 10% of pheochromocytoma cases. The main site of distant metastasis is the liver. Hypertensive crisis due to catecholamine oversecretion is potentially fatal. We present a case of malignant pheochromocytoma with multiple liver metastases. A 60-year-old female with repeated hypertensive episodes was diagnosed with malignant pheochromocytoma. She underwent a left adrenalectomy and partial hepatectomy with resection of segment 6. Catecholamine levels remained high after surgery and she received repeated cycles of chemotherapy. Four months after surgery, multiple liver metastases were detected. In spite of ongoing chemotherapy, catecholamine levels eventually became uncontrollable. Serum and urine noradrenaline and vanillylmandelic acid levels increased, but adrenaline and dopamine levels stayed within the normal range. Preoperative liver imaging revealed multiple metastases in all segments except segment 4. Percutaneous transhepatic portal vein embolization (PTPE) of the right and lateral branches of the portal vein was performed. The functional liver volume of segment 4 increased after PTPE. Right hepatectomy, lateral segmentectomy and partial resection of segment 1 were performed 10 mo after the initial surgery. Intraoperative ultrasonography detected two small tumors in segment 4, which were treated with intraoperative microwave coagulation therapy. Noradrenaline levels normalized immediately after the second hepatectomy. As there was increased telomerase activity in the resected specimen, she received adjuvant chemotherapy. She remained in good health for 2 years. However, further metastases eventually occurred and she subsequently died due to a brain hemorrhage. Hepatectomy may be a therapeutic option for reduction of tumor mass in pheochromocytoma with liver metastases.

Assessment of liver graft function and regeneration by galactosyl-human serum albumin (99mTc-GSA) liver scintigraphy in adult living-donor liver transplantation.

BACKGROUND: In adult living-donor liver transplantation (LDLT), the assessment of the graft functional reserve is very important. We evaluated the graft functional reserve by technetium-99m-diethylenetriaminepenta-acetic acid-galactosyl-human serum albumin ((99m)Tc-GSA) liver scintigraphy. PATIENTS AND METHOD: From May 2003 to September 2006, (99m)Tc-GSA studies were performed in 27 adult recipients on two, four wk after LDLT, the receptor index [ratio of liver to heart-plus-liver radioactivity at 15 minutes (LHL15)] (LHL15) was calculated. Recipients were divided into two groups according to LHL15 on two wk after LDLT (group H; >0.935, group L; <0.935). Liver functional tests and recipients' background parameters were evaluated between the two groups. RESULT: Group L accompanied higher preoperative model for end-stage liver disease (MELD) score (p = 0.038), lower graft-recipient weight ratio (GRWR) (p = 0.032) and older donor age (p = 0.003) compared with group H. There was no significant difference in the graft regeneration rate between two groups. The three-yr cumulative survival rate was 76.1% in group L and 88.9% in group H. CONCLUSION: In LDLT, LHL15 has the potential to assess the graft function and predict the recipients' outcome. Graft function after LDLT may be related closely to the pretransplant MELD score, GRWR, and donor age.

Hepaticojejunostomy by interventional radiology with an expandable metallic stent after extended right hepatectomy for hilar cholangiocarcinoma: case report.

As a rare complication of extended right hepatectomy with portal vein resection, we were unable to find the cut end of the bile duct of the lateral segment to create a hepaticojejunostomy in a 57-year-old man with hilar cholangiocarcinoma. However, we succeeded in safely creating a hepaticojejunostomy between the bile duct of the lateral segment and a Roux-en-Y jejunum by using the guide wire technique and an expandable metallic stent under fluoroscopic and cholangioscopic guidance after the operation. The patient was discharged with an internal biliary drainage tube, but died of recurrence about 2 years after the operation with the hepaticojejunostomy remaining patent.

Optimal systemic hemodynamic stability for successful clinical outcomes after adult living-donor liver transplantation: prospective observational study.

BACKGROUND AND AIM: Most living-donor liver transplantation (LDLT) recipients show characteristic systemic hemodynamics due to liver cirrhosis, and systemic hemodynamics after LDLT influenced postoperative graft function corresponding to outcomes. However, identities of optimal systemic hemodynamics for excellent outcomes and precise parameters for clinical strategy remain unclear. METHODS: Therefore, we performed prospective study in adult LDLT recipients from 2003. Hemodynamic parameters were prospectively recorded, and were analyzed in 40 recipients classified into three groups: cirrhotic (group I-C) or non-cirrhotic recipients (group I-NC) with good outcomes, and cirrhotic recipients (group II-C) without good outcomes. RESULTS: Group I-C retained characteristic hyperdynamics even after LDLT. However, absolute values of parameters revealed no significant differences between groups I-C and II-C, because group II-C also tended to show hyperdynamics. It is suggested that successful outcomes in cirrhotic recipients require maintenance of optimal hyperdynamic stability after LDLT, because cirrhotic vascular alterations still occurred. Because hemodynamic behaviors were different between groups I-C and I-NC, absolute values were also significantly different even in these successful two groups. Thus, absolute values themselves were not necessarily satisfactory for accurate evaluation of optimal hemodynamic stability. Cirrhotic hyperdynamics are symbolized in large blood volume (BV) circulated by high cardiac output (CO); therefore, we standardized CO against BV. CO/BV was significantly different between groups I-C and II-C, reflecting subtle variability of hyperdynamics in groups II-C, and was interestingly constant in the two successful groups. Therefore, CO/BV reliably evaluated optimal hemodynamic stability after LDLT, and accurately predicted outcomes. CONCLUSION: Identification of inappropriate hemodynamics after LDLT is advantageous to further improve LDLT outcomes.

Survival rates according to the Cancer of the Liver Italian Program scores of 345 hepatocellular carcinoma patients after multimodality treatments during a 10-year period in a retrospective study.

BACKGROUND AND AIM: The Cancer of the Liver Italian Program (CLIP) score has been demonstrated to have superior prognostic ability in hepatocellular carcinoma (HCC) patients worldwide, but there has never been sufficient assessment of the efficacy of treatment modalities according to the CLIP score. This retrospective cohort study of HCC patients was conducted to assess the efficacy of treatment modalities according to the CLIP score. METHODS: We compared the efficacy of hepatic resection (HR) (n = 101), radiofrequency ablation with prior transcatheter arterial chemoembolization (RFA + TACE) (n = 115), percutaneous ethanol injection with prior TACE (PEI + TACE) (n = 43), and TACE (n = 86) as a primary treatment in terms of survival among 345 patients treated at Mie University Hospital between 1995 and 2004, according to CLIP score. RESULTS: The overall survival rates in the RFA + TACE group were significantly higher in the patients with CLIP scores of 1, 2, and 3 or more (5-year, 70.9%; 3-year, 73.7%; and 3-year, 100%, respectively), but they were not significantly different from the 5-year survival rates of the HR group with a CLIP score of 0 (83.7%). Among the patients with a CLIP score of 0, a significantly higher disease-free survival rate (5-year: 33.7%) was obtained in the HR subgroup (n = 35) than in the RFA + TACE subgroup (n = 35), both of which were followed since 2000, but morbidity (21.8%) was highest in the HR group. CONCLUSION: RFA + TACE is concluded to be a safe treatment modality with better overall survival (5-year, > 60%) in HCC patients regardless of their CLIP score.

Stability of cirrhotic systemic hemodynamics ensures sufficient splanchnic blood flow after living-donor liver transplantation in adult recipients with liver cirrhosis.

AIM: To investigate the correlation between systemic hemodynamics and splanchnic circulation in recipients with cirrhosis undergoing living-donor liver transplantation (LDLT), and to clarify how systemic hemodynamics impact on local graft circulation after LDLT. METHODS: Systemic hemodynamics, indocyanine green (ICG) elimination rate (K ICG) and splanchnic circulation were simultaneously and non-invasively investigated by pulse dye densitometry (PDD) and ultrasound. Accurate estimators of optimal systemic hyperdynamics after LDLT [i.e., balance of cardiac output (CO) to blood volume (BV) and mean transit time (MTT), defined as the time required for half the administered ICG to pass through an attached PDD sensor in the first circulation] were also measured. Thirty recipients with cirrhosis were divided into two groups based on clinical outcomes corresponding to postoperative graft function. RESULTS: Cirrhotic systemic hyperdynamics characterized by high CO, expanded BV and low total peripheral resistance (TPR) were observed before LDLT. TPR reflecting cirrhotic vascular alterations was slowly restored after LDLT in both groups. Although no significant temporal differences in TPR were detected between the two groups, CO/BV and MTT differed significantly. Recipients with good outcomes showed persistent cirrhotic systemic hyperdynamics after LDLT, whereas recipients with poor outcomes presented with unstable cirrhotic systemic hyperdynamics and severely decreased K ICG. Systemic hyperdynamic disorders after LDLT impacted on portal venous flow but not hepatic arterial flow. CONCLUSION: We conclude that subtle systemic hyperdynamics disorders impact on splanchnic circulation, and that an imbalance between CO and BV decreases portal venous flow, which results in critical outcomes.

Timing of ischaemia/reperfusion before hepatectomy without inflow occlusion determines liver damage in rats: role of heat shock protein 70.

BACKGROUND: Living donor hepatectomies in liver transplantation are usually performed without inflow occlusion. We hypothesized that selective ischaemia/reperfusion (SIR) before partial hepatectomy (PH) without inflow occlusion might exert a hepatoprotective effect. METHODS: In the SIR groups, rats were subjected to a selective 30-min ischaemia to the liver that remained after PH, followed by various durations of reperfusion before 70% PH without inflow occlusion. The control group underwent 70% PH alone. RESULTS: As assessed by serum aspartate and alanine aminotransferase levels, 30-min reperfusion was highly protective against liver injury compared with 10-min reperfusion, showing the same levels as that of the control group. After PH in the 10-min reperfusion group, apoptotic cells were significantly higher and the 7-day survival rate was significantly lower than that of the 30-min reperfusion group and the control group. In the 30-min reperfusion group, the expression of heat shock protein 70 (HSP70) was significantly higher than that in the 10-min reperfusion group, while apoptosis was improved to the levels of the control group. In the SIR groups, liver regeneration was significantly enhanced, with markedly increased levels of interleukin 6 (IL-6) compared with the control group. CONCLUSIONS: The timing of SIR before PH without inflow occlusion seemed to be the most important factor for determining liver damage and survival in the context of HSP70 production, while high levels of IL-6 appear to be associated with liver regeneration after PH. The procedure of SIR before PH is not recommended because the SIR groups did not overcome the control group.

Noradrenalin-secreting retroperitoneal schwannoma resected by hand-assisted laparoscopic surgery: report of a case.

A 66-year-old woman was admitted to our hospital for investigation of a retroperitoneal mass. She was asymptomatic but her serum noradrenalin and vanillylmandellic acid levels were increased remarkably. Computed tomographic angiography showed a mass in the left side of the superior mesenteric artery (SMA) divergence, 6 x 4 cm in size, supplied mainly by the left adrenal artery. We performed hand-assisted laparoscopic surgery (HALS) using a Cavitron ultrasonic surgical aspirator. Abdominal exploration revealed that the tumor was located in the left side of the SMA root, but was not adhered to the adjacent organs. Her vital signs remained stable during the operation. Microscopic examination revealed a palisade formation, confirming a histopathological diagnosis of degenerated schwannoma (Antoni type B). Immunohistologically, the tumor cells were stained with S-100 protein and neuron-specific enolase. Her noradrenalin level normalized immediately after the operation and she remains in good health 3 years 2 months later.

The role of living-donor liver transplantation in surgical treatment for hepatocellular carcinoma.

BACKGROUND/PURPOSE: The role of living-donor liver transplantation (LDLT) in the surgical treatment of patients with hepatocellular carcinoma (HCC) has not been established as yet. METHODS: Preliminary experience gained from 24 patients who underwent LDLT for HCC between March 2002 and November 2004, and the results of the 131 patients who underwent hepatic resection (HR) for HCC between January 1990 and December 2003 were retrospectively analyzed. The exclusion criteria for LDLT for HCC included extrahepatic metastasis and major vascular invasion. RESULTS: (1) LDLT: the median age of the patients was 57 years and the Child-Pugh grades (A/B/C) of the patients were 6, 12, and 6, respectively. The tumor size was 3 cm or less in 15 patients, multinodular tumors were present in 23 patients, and 11 patients (45.8%) met the Milan Criteria. The overall 2-year survival rate was 72.3%, without a significant difference as to whether or not patients met the Milan criteria. (2) HR: on multivariate analysis, the Child-Pugh grade, the presence of cirrhosis, and the number of tumor nodules were considered as independent risk factors for unfavorable survival (P < 0.05). The 84 patients who met the Milan criteria and were Child-Pugh grade A had a 5-year survival rate of 71.3%; this was significantly better than those of the other patients (P < 0.005). Among the 57 patients with intrahepatic recurrence, 18 patients who were Child-Pugh grade A, met the Milan criteria, and were treated by re-resection or ablation therapy achieved a significantly better 5-year survival rate, of 73.1%, as compared to 19.7% in the other 39 patients (P < 0.0045). CONCLUSIONS: HR could be a first-line treatment with a favorable prognosis for patients who have resectable HCC, preserved liver function, and who meet the Milan criteria. Salvage LDLT could be employed in patients with recurrent tumors that cannot be controlled by conventional treatment or in patients in whom liver function has deteriorated to Child-Pugh grade B or C.

Primary liposarcoma of gallbladder diagnosed by preoperative imagings: a case report and review of literature.

A 49-year-old Japanese woman was referred to our department because of high fever and a huge abdominal mass. Computed tomography (CT) and magnetic resonance (MR) imagings revealed a tumor, about 30 cm in diameter,occupied the right hepatic lobe and the peritoneal cavity. Abdominal angiography showed that the tumor was fed mainly by the cystic artery. We preoperatively diagnosed angiosarcoma of the gallbladder and performed tumor resection with cholecystectomy because the tumor was almost capsulated,however the posterior wall of the gallbladder attached to the tumor firmly. Histologically,the tumor was composed of spindle cells including lipoblasts with cellular pleomorphism, which were also detected in the muscular layer of the gallbladder. We finally diagnosed pleomorphic liposarcoma of the gallbladder. At 10 mo and 29 mo after the first operation, she underwent two more operations because of recurrence. Now she has a good quality of life 3 yr and 6 mo after the first operation.

K(ICG) value, a reliable real-time estimator of graft function, accurately predicts outcomes in adult living-donor liver transplantation.

Reliable monitoring enabling evaluation of graft function is crucial after living-donor liver transplantation (LDLT). A method to identify poor graft function at an early postoperative period would allow opportune intensive clinical management to bring about further improvements in LDLT outcomes. This study assessed the reliability of the indocyanine green (ICG) elimination rate constant (K(ICG)) value as an estimator of graft function and determined the actual temporal changes of K(ICG) after LDLT. K(ICG) values were measured using a noninvasive method in 30 adult recipients up to 28 days after LDLT. The receptor index (LHL15) based on liver scintigraphy, and graft parenchymal damage score based on histopathological findings were evaluated after LDLT and correlated well with simultaneous K(ICG). Thus, K(ICG) measured by noninvasive method was confirmed as accurately evaluating graft function. Changes of K(ICG) after LDLT in recipients with good graft function were maintained, after some falls in the early periods, and had a significant difference compared with those for recipients without good graft function; moreover, there were already significant differences in K(ICG) 24 hours after LDLT. Mean transit time reflecting systemic hemodynamics revealed that recipients without good outcomes fell into an unstable systemic hemodynamic state, and effective hepatic blood flow has a large influence on liver regeneration after LDLT. In conclusion, we suggested that K(ICG) values can predict clinical outcomes at the early postoperative period after LDLT by sharply reflecting the influence of systemic dynamics on splanchnic circulation.

Optimal portal venous circulation for liver graft function after living-donor liver transplantation.

BACKGROUND: Previous studies have shown poor outcome after living-donor liver transplantation (LDLT) as a result of excessive portal venous pressure (PVP), excessive portal venous flow (PVF), or inadequate PVF. We investigated optimal portal venous circulation for liver graft function after LDLT in adult recipients retrospectively. METHODS: Between June 2003 and November 2004, 28 adult patients underwent LDLT in our institution. We modulated PVP under 20 mmHg in these 28 cases by performing a splenectomy (n=4) or splenorenal shunt (n=1). The PVF and PVP were measured at the end of the operation. Compliance was calculated by dividing PVF by PVP. RESULTS: PVF and compliance showed a significant inverse correlation with peak billirubin levels after LDLT (r = -0.63: r=-0.60, P<0.01), and with peak international normalized ratio after LDLT (r=-0.41: r=-0.51, P<0.05). Compliance was higher in right-lobe graft with middle hepatic vein cases (148+/-27 ml/min/mmHg), and lower in left-lobe graft cases (119+/-50 ml/min/mmHg). CONCLUSIONS: Liver graft function was better when PVF and graft compliance were higher and PVP was maintained under 20 mmHg.

Donor outcome and liver regeneration after right-lobe graft donation.

Sufficiently detailed information on donor safety and the liver regeneration process following right-lobe living donation has been unavailable, so we evaluated donor outcome and liver regeneration in 13 males and 14 females (39.0 +/- 14.8 years old) who provided 27 right-lobe grafts without the middle hepatic vein. Preoperative total liver volume (TLV), graft volume, and postoperative changes in residual liver volume (RLV) were measured by volumetric computed tomography. Histological steatosis of the liver was graded as none, minimal (< or =10%), and mild (11-30%). The median follow-up period was 337 days. Estimated graft volume and actual graft weight were linearly correlated (Y = 177.85 + 0.795X, R(2) = 0.812, P < 0.0001). Graft-to-recipient weight ratio was 1.08 +/- 0.19%. Four donors had postoperative complications, but they resolved in response to conservative treatment. Postoperative hospital stay was 15.2 +/- 5.5 days. Peak liver enzyme values were significantly higher in donors with mild steatosis (n = 7) than without steatosis (n = 16) (P < 0.05). Donor RLV was 40.8 +/- 6.6% of original TLV at surgery, 79.8 +/- 12.0% by 6 months, and 97.2 +/- 10.8% by 12 months. At 3 months the liver of the older donors (> or =50 years) had grown significantly more slowly than in younger donors (70.4 +/- 9.2% vs. 79.3 +/- 9.6%, P = 0.0391). In conclusion, right hepatectomy without middle hepatic vein of living donors is a safe procedure with acceptable morbidity, and the residual liver regenerated to its preoperative size by 1 year. However, meticulous care should be taken in donors with liver steatosis and aged donors.

Outflow block secondary to stenosis of the inferior vena cava following living-donor liver transplantation?

Although it is well known that outflow block is caused by stenosis or occlusion of hepatic vein anastomoses following living donor liver transplantation (LDLT), there have been few reports on inferior vena cava (IVC) stenosis following LDLT. In this paper, we report two cases of IVC stenosis and hepatic vein outflow block following right hepatic LDLT in the absence of stenosis of any of the anastomoses. Both patients presented with liver dysfunction, an ascitic fluid volume of approximately 2000 mL, and congestion in their biopsy specimens, and venocavography demonstrated IVC stenosis with gradients of more than 10 mmHg in patients with a dominant inferior right hepatic vein (IRHV) anastomosis. After a Gianturco expandable metallic stent successfully implanted in the IVC, the patient's liver function recovered and the volume of ascitic fluid decreased. The pathogenesis of hepatic vein outflow block secondary to IVC stenosis following LDLT may involve the anastomosis with the IRHV, which is the dominant draining vein of the graft and larger than the RHV, caudal to the IVC stenosis and a significant IVC pressure gradient that results in increased IRHV pressure. In conclusion, it is important to include hepatic vein outflow block in the differential diagnosis when patients who have undergone right hepatic LDLT in which anastomosis of the large IRHV has been performed develop manifestations of liver dysfunction.

Using a radial artery as an interpositional vascular graft in a living-donor liver transplantation for hepatocellular carcinoma.

With increasing numbers of living-donor liver transplantations (LDLTs) for hepatocellular carcinoma (HCC), cases with some arterial troubles are encountered; because most HCC cases waiting for LDLT have undergone interventional treatments. In these patients, the reconstruction of the graft artery needs to be planned preoperatively. We report a 52-year-old male, with hepatitis C-related liver cirrhosis and advanced HCC, who for 4 years repeatedly underwent continuous intraarterial chemotherapy through an implanted reservoir port. A suitable artery was not available for arterial reconstruction and the patient underwent LDLT using an autologous radial artery conduit based on the infrarenal aorta. Postoperatively, the patient is well with normal liver function and efficient arterial flow. Autologous radial artery can be safely and successfully used as an aortic-based arterial conduit when HCC patients waiting for LDLT have undergone long-term repeated intraarterial chemotherapy.

Approach to fine-needle aspiration cytology-negative cases of breast cancer.

OBJECTIVE: To clarify the clinical usefulness of fine-needle aspiration (FNA) cytology of breast tumours and the management of FNA cytology-negative cases suspected of or equivocal for malignancy. METHODS: FNA cytology was performed in 94 patients between 1995 and 2002. We calculated the sensitivity, specificity and accuracy of FNA cytology for the diagnosis of malignancy. We also compared clinical and radiological findings between false-negative and true-negative cases. RESULTS: The sensitivity of FNA was 91% (72/79), specificity was 93% (14/15), accuracy was 91% (86/94), positive predictive value was 99% (72/73) and negative predictive value was 67% (14/21). There were seven false-negative cases and one false-positive case. Findings that aroused suspicion of malignancy were more frequent in the false-negative cases, especially from mammography and magnetic resonance imaging (MRI). CONCLUSION: FNA cytology was an accurate preoperative diagnostic procedure for the evaluation of breast masses. In FNA cytology-negative cases, repeated FNA, core needle biopsy or excisional biopsy needs to be performed based on MRI findings.

Laparoscopic spleen-preserving pancreatic tail resection for an intrapancreatic accessory spleen mimicking a nonfunctioning endocrine tumor: report of a case.

Laparoscopic surgery is now performed for several pancreatic disorders, such as benign tumors of the pancreatic body or tail, which are a good indication for laparoscopic resection. However, the risk of pancreatic fistula after distal pancreatectomy, performed laparoscopically or by open surgery, is a topic of debate. We report the case of a 61-year-old man in whom a routine follow-up computed tomography (CT) scan showed a solid, well-defined mass, 1.5 cm in diameter, in the pancreatic tail. The mass was homogeneously enhanced from the early phase to the super-delayed phase on enhanced CT. We suspected a nonfunctioning endocrine tumor of the pancreas, and surgery was performed laparoscopically. After dissecting the pancreatic tail away from the splenic hilum and the splenic vessels, it was resected using only a linear stapler. The histological diagnosis was an intrapancreatic accessory spleen. The patient was discharged on postoperative day 14, but was readmitted 6 days later because of a pancreatic fistula, which was treated by CT-guided percutaneous drainage.

Intrahepatic hepatic vein stenosis after living-related liver transplantation treated by insertion of an expandable metallic stent.

Although the incidence of stenosis and obstruction of the hepatic venous anastomosis after right hepatic living-related liver transplantation (LRLT) has been found to be higher than after orthotopic liver transplantation (OLT), to the best of our knowledge, intrahepatic stenosis of the venous trunk in the early period after right hepatic LRLT has never been reported in the literature. A 53-year-old man who underwent right hepatic LRLT, postoperatively, developed liver dysfunction and an increasing amount of ascites, and a Doppler sonogram showed a flat waveform and low-flow velocity in the hepatic vein. Based on these findings an outflow block was suspected, and a hepatic venogram and manometry revealed intrahepatic stenosis of a tortuous hepatic venous trunk and a pressure gradient of 14 mmHg at the site of the stenosis. We inserted an expandable metallic stent (EMS) at the site of intrahepatic venous stenosis, and its insertion was followed by a decrease in pressure gradient. Liver function recovered, and the volume of ascitic fluid decreased after placement of the EMS. The results of an analysis of the venogram and CT volumetric data suggested that the pathogenesis of the stenosis was twisting of the venous trunk during hypertrophy of the liver parenchyma.

Laparoscopic splenectomy for a huge splenic cyst without preoperative drainage: report of a case.

Laparoscopic splenectomy currently is a safe procedure and offers better cosmetic results, less pain, and a shorter hospital stay than the traditional open procedure. However, there have been only a few reports of laparoscopic removal of giant splenic cysts. An 18-year-old woman was admitted with abdominal fullness. CT scans and MRI images of the upper abdomen revealed a cystic mass having a diameter of 19 cm. Preoperative diagnosis was a large splenic cyst, and laparoscopic splenectomy with intraoperative cyst drainage (amount of drained fluid: 3,000 mL) was performed. Histologically, almost the entire cyst wall was lined with fibrous tissue, but a small portion was covered with stratified squamous epithelium. The final diagnosis was epidermoid cyst. The postoperative course was uneventful. Laparoscopic splenectomy should be tried first even in patients with a huge cyst, and intraoperative drainage under laparoscopic guidance facilitates laparoscopic splenectomy.

Bacterial analysis of infected pancreatic necrosis and its prevention (Symposium 8: Pancreatobiliary infection (IHPBA)).

In severe acute pancreatitis, sepsis mainly due to pancreatic or peripancreatic infection have emerged as the most serious complications and now accounts for more than 80% of deaths. Collective review of organisms associated with secondary pancreatic infection in patients with acute pancreatitis has revealed that most of them are intestinal flora. Several experimental studies including ours have revealed that acute pancreatitis promotes bacterial translocation (BT), which in turn leads to infection of the pancreas and septic complications. Prophylactic antibiotics given intravenously have been demonstrated to be beneficial in reducing the rate of pancreatic infection, but their survival benefit remains unclear. We have demonstrated that continuous regional arterial infusion (CRAI) of an antibiotic is more effective than intravenous administration in preventing pancreatic infection and improving survival, in a canine model of acute necrotizing pancreatitis. Our recent experimental study has revealed that CRAI of an antibiotic via the superior mesenteric artery (SMA) is effective in mitigating intestinal mucosal damage and preventing BT in acute pancreatitis, thereby improving survival. BT aggravates pancreatic necrosis and remote organ damage in acute pancreatitis, and SMA infusion of antibiotics is effective in preventing BT and is practical for clinical use.