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Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Objective:  The aim of this study was to determine the factors related to functional patella alta, with which the proximodistal patellar position exceeds the reference range of healthy small dogs proximally when the stifle is at full extension., Study Design:  Mediolateral-view radiographs of dogs weighing less than 15 kg were obtained and classified into the medial patellar luxation (MPL) and control groups. The reference range of the proximodistal patellar position was determined from the control group. In both groups, a patellar position exceeding this reference range proximally was considered functional patella alta. Multiple logistic regression analysis was performed to examine the factors related to functional patella alta. A receiver operating characteristic (ROC) curve was made for each factor., Results:  Overall, radiographs of 127 stifles of 75 dogs were obtained. Eleven stifles in the MPL group and one stifle in the control group were determined to be functional patella alta. The factors associated with functional patella alta included a greater full extension angle of the stifle joint, longer patellar ligament, and shorter femoral trochlear length. The full extension angle of the stifle joint had the biggest area under the ROC curve., Conclusion:  Mediolateral radiographs of the stifle joint in full extension are clinically important in dogs with MPL because some dogs might have a proximally positioned patella that is recognizable only when the stifles are extended., Competing Interests: None declared., (Thieme. All rights reserved.)

Exhaustive exercise is known to induce acute renal damage. However, the precise mechanisms remain unclear. We investigated the effects of macrophage depletion on exhaustive exercise-induced acute renal damage. Male C57BL/6 J mice were divided into four groups: sedentary with control liposome (n=8), sedentary with clodronate liposome (n=8), exhaustive exercise with control liposome (n=8), and exhaustive exercise with clodronate liposome (n=8). Mice were treated with clodronate liposomes or control liposomes intraperitoneally for 48 h before undergoing exhaustive exercise. Renal function and renal histology were tested at 24 h. The expression levels of kidney injury molecule (KIM)-1 and inflammatory cytokines in kidney tissues were measured by quantitative RT-PCR, and KIM-1 concentration was semi-quantified by immunostaining. As a result, exhaustive exercise increased macrophage infiltration into the kidney. However, clodronate reduced it. Although exhaustive exercise resulted in an increase in KIM-1 mRNA expression levels and concentration, injection of clodronate liposome reduced it. In addition, TUNEL positive apoptotic cells were increased after exercise, but significantly reduced by clodronate. Clodronate liposome treatment also decreased the mRNA expression levels of inflammatory cytokines (TNF-α, IL-1β, and IL-6) in the kidney after exhaustive exercise. These results suggest that macrophages play a critical role in increasing renal damage by regulating inflammation., Competing Interests: The authors declare that they have no conflict of interest., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Objective:  The aim of this study was to clarify the histological effects of tibial plateau levelling osteotomy on cranial cruciate ligament degeneration induced by excessive tibial plateau angle., Study Design:  Five female Beagles were used to bilaterally create excessive tibial plateau angle models surgically. A second tibial plateau levelling osteotomy was performed 11 months after the first surgery on the right stifle (tibial plateau levelling osteotomy group), and a sham operation that did not change the tibial plateau angle was performed on the left stifle (excessive tibial plateau angle group). At 6 months after the second surgery, the dogs were euthanatized. The cranial cruciate ligament was stained with haematoxylin-eosin to assess the cell density, Alcian-Blue to assess proteoglycans and Elastica-Eosin to assess elastic fibres, and immunohistochemically stained to assess type I (COL1) and type II collagen and SRY-type HMG box 9 (SOX9) expression., Results:  In each group, the cranial cruciate ligament degeneration, especially on the tibial side, including the presence of Alcian-Blue- and Elastica-Eosin-positive regions, decreased in COL1-positive regions, and enhancement of SOX9 expression was observed. Besides, compared with the tibial plateau levelling osteotomy group, the excessive tibial plateau angle group showed increases in Alcian-Blue- and Elastica-Eosin-positive regions and a decrease in the COL1-positive regions., Conclusion:  The results suggested that excessive tibial plateau angle-induced cranial cruciate ligament degeneration can be suppressed by reducing the biomechanical load on the cranial cruciate ligament by performing tibial plateau levelling osteotomy., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective:  This study aimed to evaluate implant-induced osteoporosis (IIO) development in toy breed dogs treated using internal fixation with digital radiographs as the index of pixel values., Study Design:  There were 226 cases (236 limbs) of toy breed dogs with radial-ulnar fractures. Pixel values were measured on radiographs immediately, 2 weeks and 1 to 12 months after surgery. The ratio of pixel values (PVR) represented the bone mineral areal density based on the humeral condyle in the same image. The dogs were grouped based on the fixation methods, age and status of destabilization., Results:  There was a significant decrease in the PVR at 1 to 12 months postoperatively for all cases. There were not any significant differences in PVR of antebrachial fractures between those repaired with plates using locking head screws, cortex screws or a combination of locking and cortex screws. Implant-induced osteoporosis persisted at 1 to 12 months postoperatively in dogs aged ≧6 months, while the PVR increased after 3 months in dogs aged <6 months. Based on the destabilization method, there was a significant increase in the PVR at 3 months in the plate removal group., Conclusion:  This study suggests that IIO occurs in small dogs treated with plates and screws. Moreover, patients aged < 6 months showed an early postoperative recovery of bone mineral areal density. Further, screw and plate removal could contribute to the recovery of bone mineral areal density., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective:  The aim of the study was to determine the changes in biomechanical characteristics following tibial plateau levelling osteotomy (TPLO) using simulated manual tests., Study Design:  Twenty-one stifles from healthy Beagle dogs that had undergone TPLO or had not (control) were first tested in the intact form, and then the cranial cruciate ligament (CrCL) was transected in each to provide four test situations: control-intact, control-CrCL-transected, TPLO-intact and TPLO-CrCL-transected. The stifles were then analysed using a robotic joint biomechanical testing system. The craniocaudal drawer, axial rotation and proximal compression tests were applied., Results:  The craniocaudal displacement during the drawer test was not significantly different between the control-intact and TPLO-intact. However, the displacement was significantly greater in the TPLO-CrCL-transected than in the control-intact. In the axial rotation test, the internal-external (IE) rotation was significantly greater in the TPLO-intact than in the control-intact. Similarly, the IE rotation was significantly greater in the TPLO-CrCL-transected than in the control-CrCL-transected. In the proximal compression test, craniocaudal displacement was not significantly different among the control-intact, TPLO-intact and TPLO-CrCL-transected., Conclusion:  These findings suggest that TPLO influences the tension of the collateral ligaments and might generate laxity of the tibiofemoral joint. Instability after the osteotomy might be associated with the progression of osteoarthritis., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective:  The aim of this study was to describe a new surgical method of segmental femoral ostectomy for the reconstruction of the femoropatellar joint (FPJ) in dogs with medial patellar luxation (MPL) grade IV., Study Design:  The medical records of six dogs that underwent segmental femoral ostectomy to reconstruct the FPJ for MPL grade IV were retrospectively reviewed. The data included breed, age, body weight, comorbidities, history of orthopaedic abnormalities, pre- and postoperative radiographic findings, morphological indicators measured on three-dimensional computed tomographic multiplanar reconstruction images, surgical methods and postoperative complications., Outcomes:  Eleven hindlimbs with MPL grade IV in six dogs underwent segmental femoral ostectomy to reconstruct the FPJ with the four basic surgical procedures. Six stifle joints with femoral varus deformity were treated by closing wedge ostectomy and segmental ostectomy, while five stifle joints were treated by segmental ostectomy alone. The mean resected femoral length was 11.7 mm. The mean resected femoral length relative to the preoperative femoral length was 14.3%. The stability and congruity of the FPJ was markedly improved, with an increased range of motion in all dogs compared with their preoperative status., Conclusion:  Segmental femoral ostectomy was a useful treatment method for MPL grade IV with shortened quadriceps muscle length relative to the femoral length. Reconstruction of the FPJ is important for recovery of limb function., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Objectives:  Dogs with patella alta reportedly have a shorter extensor mechanism than normal dogs. The present study aimed to measure the length of the extensor mechanism and to assess the effect of limb position on the quadriceps muscle length (QML)/femoral bone length (FL) ratio., Study Design:  Three-dimensional computed tomography images were taken of 12 Beagle dogs. Each dog underwent computed tomographic imaging 24 times with different limb positions. The QML/FL was measured on each image, along with the hip flexion-extension, hip abduction-adduction and stifle flexion-extension angles. Multiple regression analysis was used to determine the effect of these angles on the QML/FL., Results:  The QML/FL was increased with the hip extended (standardized partial regression coefficient 0.855 with linear plotting, 0.829 with log plotting) and with the stifle flexed (standardized partial regression coefficient 0.814 with linear plotting, 0.800 with log plotting). The partial regression coefficient of the hip abduction-adduction angle was small, indicating a small impact on the QML/FL. The 95% confidence range of the QML/FL with the hip extended and stifle flexed was 0.87 to 1.00 (mean ± standard deviation: 0.93 ± 0.03)., Conclusion:  The QML/FL was more influenced by joint angles when the hip was flexed or the stifle was extended. Hence, these positions should be avoided when evaluating the QML/FL so that the QML is less altered by slight positioning disparities., Competing Interests: None declared., (Georg Thieme Verlag KG Stuttgart · New York.)

Background/aims: This study was conducted to assess the usefulness of multi-slice CT (MDCT) and diffusion weighted MR images (DWI-MRI) for diagnosis of metastatic lymph nodes (LNs) in biliary carcinomas., Methodology: Eighteen patients with biliary carcinomas (total 121 LNs) underwent surgical resection were included. In MDCT, the following criteria were measured: the maximum diameter, the enhanced value and the long and short axis (L/S) ratio. In DWI-MRI, the apparent diffusion coefficients (ADCs) were measured from ADC maps., Results: In ROC analysis, the maximum diameter has the highest diagnostic power with area under curves of 0.903. And when the maximum diameter 8 mm and L/S ratio is less than 2, the accuracy was improved with a sensitivity of 81%, positive predictive value (PPV) of 45%. In DWI-MRI, ADCs values of metastatic LNs significantly lower than that of non-metastatic LNs (mean: 1.65 vs. 2.11 x10 3mm2/s). When the ADC value of 1.8 x10(-3) was used as a cut-off value, the best results were obtained with sensitivity of 75%, PPV of 82%., Conclusions: Using MDCT, diagnosis of LNs metastasis should be more than 8mm diameter and less than 2 of L/S ratio. In addition, DWI-MRI is more useful modality for diagnosis of LNs metastasis.

In this study, we demonstrated the complete resection of untinate process that was performed by the hybrid laparoscopic surgery using our original new technique of Shuriken shaped umbilicoplasty with sliding window`s method. A 70-year-old weman was hospitalized for surgery of intraductal papillary mucinous neoplasm located in the uncinate process of pancreas. Under general anesthesia, a Shuriken shaped umbilical skin incision was made by 7 cm in horizontal and 4cm longitudinal width with 3cm round skin incision. The intermediate skin between outside and inside skin incision was removed. Subcutaneous tissue around the umbilicus and the upper abdominal subcutaneous region was dissected, and the 8cm of upper abdominal minilaparotomy was performed. The complete resection of untinate process was performed by hybrid laparoscopic procedure with the hand-assisted or the laparo-assisted manner. The umbilicoplasty of only 3cm round skin wound was made by the reefing of subcutaneous suture with 5-0 absorbable suture. The patient suffered from pancreas leakage from pancreas stump, however it was recovered spontaneously. Our new procedure could be used for PD, DP, and Major hepatectomy with the hybrid laparoscopic procedure. It might be considered that our method is good for both cosmetic and safety benefits in HPB surgery.

Background/aims: Cancer stem cells (CSC) was reported to play an important role in various kinds of cancer. CD133 is one of the cancer stem cell markers in solid cancers. However, the correlation between CD133 expression and the clinicopathological factors in colorectal cancer (CRC) remains unclear., Methodology: Forty patients with CRC who underwent operations were enrolled. Expression of CD133 was investigated by immunohistochemistry (IHC). The staining was observed in the cytoplasm of cancer cells and the patients who have the staining were defined as CD133-positive cases. The patients were divided into two groups: the CD133-positive group (n = 22) and negative group (n = 18). Clinicopathological factors were compared between the two groups. The prognostic factors were investigated by multivariate analysis., Results: In the CD133-positive group, the incidence of lymph node and liver metastasis, lymphatic and venous invasion, as well as the progression of stage of cancer were higher than that in the CD133-negative group. The 5-year survival rate and the disease-free survival rate in the CD133-positive group were lower than that in the CD133-negative group. The multivariate analysis revealed that CD133 expression tended to be an independent prognostic factor., Conclusions: CD133 expression is correlated with poor prognosis in CRC.

Background/aims: The aim of this study is to investigate the mechanisms of improvement in insulin resistance after duodenal-jejunal bypass (DIB), especially regarding the correlation between bile acids and glucagon-like peptide-1 (GLP-1)., Methodology: SD rats were divided into two groups: DIB or Sham group. Blood glucose, insulin, GLP-1, bile acids, and the number of L cells in the small intestine were investigated three weeks after the operations. Next, to assess the effect of the bile acids on GLP-1 secretion in ileum, bile diversion model (=inhibition of rapid bile exposure to the ileum; BD group) were performed and postoperative glycemic parameters were measured., Results: DJB improved insulin resistance and increased GLP-1 compared with sham. Higher bile acids in DJB were found than that in sham. The number of L cells in the common limb of DJB was increased compared with that in the distal segment of sham. In BD group, insulin resistance had not improved. GLP-1, bile acids, and the number of L cells revealed no significant changes compared with sham., Conclusions: DJB has a potential to improve insulin resistance, which may be related to enhanced GLP-1 secretion through the increase of bile acids in the common limb of the small intestine.

Background/aims: The aim of this study was to evaluate the clinico-patholigical features and effects of multi-disciplinary therapy for pediatric patients with hepatoblastoma (HB)., Methodology: Ten cases who underwent hepatectomy from 1996 to 2013 were studied. Our therapeutic protocol included neoadjuvant chemotherapy (NAC) + hepatectomy + adjuvant chemotherapy (AC). The regimens were CDDP+THP-ADR (n = 2), CITA (n = 1), PLADO (n = 5), and CDDP(n = 1). One case with 18-trisomy underwent only hepatectomy. Medical records were reviewed to evaluate characteristics, the effects of chemotherapy and prognosis., Results: The median age at operation was 1.2 years (male: 7 and female: 3). PRETEXT classification was assigned to groups I (n = 2), II (n = 4), and III (n = 4). 15 years overall survival and disease-free survival rates were 100% and 80%, respectively. Two cases, who had post-operative lung metastasis, underwent chemotherapy with or without complete resection of lung tumors. No further recurrence was observed in these two cases. One case with 18 trisomy underwent right hepatectomy for PRETEXT II HB and is still doing well 67 months after hepatectomy., Conclusions: It was found that multidisciplinary therapy based on surgery, including complete resections of recurrent lesions, offers long-term survival, even for cases which develop recurrent metastatic tumors or cases complicated with 18 trisomy.

Background/aims: Pancreaticobiliary maljunction (PBM) is well known to have carcinogenic potential. The goal of this study was to clarify the carcinogenic potential of the epithelium of choledochal cyst particularly by paying attention of HDAC1 and COX-2 expressions., Methodology: Six-week male Lewis rats were divided into two groups; 1) single dose of dibutyltin dichloride (8 mg/kg) was administered intravenously (DBTC group), 2) saline administration was done with the same manner (control group). Morphological changes of biliary tract and expressions of carcinogenesis-related genes, Ki67, HDAC1 and cyclooxygenase-2 (COX-2) were examined immunohistochemically after administration., Results: In the DBTC group, the bile duct had been gradually dilated on day 3 after administration and the biliary epithelium of dilated bile duct was papillary proliferated on day 7. Ki67 and COX-2 expressions gradually increased and reached the highest value of 6.0% and 3.6% on day 14, respectively. HDAC1 expression increased at the early postoperative period prior to other oncogene, and reached the highest level of 15% on day 7., Conclusions: These findings suggested that HDAC1 played an important role in carcinogenesis of PBM through the regulation of COX-2.

Background/aims: Laparoscopic surgery reduces the risk of postoperative adhesion compared with open surgery. The aim of this study was to assess the advantage of laparoscopic surgery in terms of postoperative adhesion., Methodology: Eleven patients participated in this study (laparoscopic surgery: 6 patients, open surgery: 5 patients). Body temperature, heart rate, the duration until the first postoperative flatus and the beginning of diet were investigated on postoperative day 0, 1, 3, and 5, respectively. Serum level of WBC and CRP, PAI-1 and IFN-gamma level in the drainage tube were also measured at the same time., Results: There is no significant difference between the two groups in body temperature. The laparoscopic group revealed significantly lower WBC on POD 0 and CRP on POD 1 compared with the open group. PAI-1 was significantly lower on POD 3 and 5 in the laparoscopic group. IFN-gamma in the laparoscopic group tended to be suppressed compared with the open group., Conclusions: Laparoscopic surgery may decrease the risk of postoperative abdominal adhesion compared with open surgery by suppressing early postoperative inflammation.

Background/aims: This study was carried out to clarify the clinicopathological features of hepatocellular carcinoma (HCC) arising in patients without viral infection and to confirm the influence of metabolic syndrome (MS) on characteristics in HCC patients., Methodology: Two hundred and thirty-three hepatectomized HCC patients were enrolled. The status of the hepatitis viral infection was defined; non-B non-C (NBNC) (n = 15), negative for HBs-Ag, HBc-Ab or HCV-Ab; HBV (n = 70); HCV (n = 148). We compared clinicopathological features and surgical outcomes among three groups. Additionally, fifty-six HCC patients who were evaluated on coexistence of MS were divided into two groups and analyzed; MS (n = 16) and non-MS (n = 40) groups., Results: In NBNC-patients, preoperative platelet counts and ICGR15 were significantly better compared to HCV-patients (21.8 x 10(4)/mm3 vs. 11.3 x 10(4)/mm3, 14.0% vs. 19.2%, p <0.05). Body mass index was significantly higher in NBNC-patients (24.9 vs. 22.4, p < 0.05). Overall survival rates were significantly higher in NBNC-patients compared with HBV or HCV-patients (5 y: 87.5% vs. 48.8%, 42.9%, p < 0.05). For NBNC-patients there were significantly more patients in the MS group than in the non-MS group., Conclusions: HCC with MS included more NBNC-HCC than HBV or HCV related HCC. Aggressive hepatectomy contributed to the favorable outcome in NBNC-patients because of their better liver function.

Background/aims: Three-dimensional CT has become an essential tool for successful hepatic surgery. Up to now, efforts have been made to simultaneously visualize hepatic vasculature and bile ducts. Herein, we introduce a new one-stop shop approach to hepatic 3D-anatomy, using a standard enhanced MDCT alone., Methodology: A 3D-reconstruction of hepatic vasculature was made using data from contrast enhanced MDCT and SYNAPSE VINCENT software. We identified bile ducts from axial 2D image, and then reconstructed the 3D image. Both hepatic vasculature and bile duct images were integrated into a single image and it was compared with the 3D image, utilized with MRCP or DIC-CT., Results: The first branches of both the right and left hepatic ducts were hand-traced and visualized for all 100 cases. The second branches of these ducts were visualized in 69 cases, and only the right second branch was recognized in 52 cases. Anomalous variations of bile ducts, such as posterior branch joining into common hepatic duct, were recognized in 12 cases. These biliary tract variations were all confirmed by MRCP or DIC-CT., Conclusions: Our new one-stop shop approach using the 3D imaging technique might contribute to successful hepatectomy as well as reduce medical costs and radiation exposure by omission of MRCP and DIC-CT.

Background/aims: Polysaccharide K (PSK) is widely used in Japan as a biological response modifier for cancer patients. We investigated the effects of PSK with S-1 based chemotherapy for advanced gastric cancer patients in immune response., Methodology: Nine advanced gastric cancer patients who underwent chemotherapy at the University of Tokushima were included in this study. In all patients, 3g PSK was received orally and S-1 based chemotherapy for 2 weeks alternately for 8 weeks. Serial changes in immunological parameters (Foxp3, Natural killer (NK), CD4/CD8) were monitored., Results: The levels of Foxp3 at 8 weeks was significantly decreased compared with 2 weeks (4.26% vs. 3.11%). In NK activity at 8 weeks was significantly increased compared with 2 weeks (27% vs. 47%)., Conclusions: These results of this study suggested that chemotherapy with PSK improved the immune response in advanced gastric cancer patients. Especially Foxp3 was concerned in this mechanism.

Background/aims: The aim of this study was to investigate the impact of preoperative serum C-reactive protein (CRP) level as a prognostic indicator in patients with colorectal carcinoma (CRC)., Methodology: We investigated the correlation between preoperative CRP level and clinicopathological factors including prognosis of 167 patients who underwent resection for CRC retrospectively. Clinicopathological variables were compared between patients with serum CRP levels >1mg/dL (29 patients; high-CRP group) and patients with serum CRP levels <1mg/dL (138 patients; low-CRP group)., Results: In high-CRP group, 9 patients were stage I+II and 20 patients ware stage III+IV. In low-CRP group, 93 patients were stage I+II and 45 patients were stage III+IV. There were significant differences in the clinical stage, tumor diameter, curativity, final stage between the two groups (p<0.01). The overall survival and recurrence-free survival rates in high-CRP group were lower compared with the rates in low-CRP group (p<0.05 and p=0.14). In addition, the overall survival rate in stage I+II patients with high-CRP was significantly lower than that in patients with low-CRP (p<0.05). Using multivariate analysis, the preoperative elevation of serum CRP level was an independent prognostic factor in patients with CRC (p<0.05)., Conclusions: We found that the preoperative elevation of serum CRP to be an independent prognostic indicator of CRC.

Background/aims: After hepatic resection, delayed flatus and impaired bowel movement often cause problematic postoperative ileus. Kampo medicine, Dai-kenchu-to (DKT), is reported to have a various beneficial effects on bowel systems. The aim of this study was to prospectively evaluate effects of DKT after hepatic resection., Methodology: Thirty-two patients who underwent hepatic resection between July 2007 and August 2008 in Tokushima University Hospital were prospectively divided into DKT group (n=16) and control group (n=16). In DKT group, 2.5 g of DKT was administered orally three times a day from postoperative day (POD) 1. Blood was examined on POD 1, 3, 5 and 7. Postoperative first flatus, bowel movement and full recovery of oral intake, hospital stays and complications were checked., Results: In DKT group, levels of c-reactive protein and beta-(1-3)-D-glucan on POD 3 were significantly decreased (p<0.05). Moreover, postoperative periods for the first flatus, bowel movement and the full recovery of oral intake were significantly shortened in DKT group (p<0.05)., Conclusions: DKT suppressed inflammatory reaction, stimulated bowel movement and improved oral intake after hepatic resection, which may decrease serious morbidity after hepatic resection.

Background/aims: Preoperative chemoradiation therapy (CRT) for advanced rectal cancer allows anal sphincter preservation in some patients who would require an abdominoperineal resection. But adequate distal margin in patients with locally advanced rectal cancer requiring preoperative CRT is unclear. The objective was to evaluate necessary distal margin from reduced tumor by preoperative CRT for anal sphincter preservation., Methodology: This study included 11 consecutive patients who performed low anterior resection and abdominoperineal resection for rectal cancer after preoperative CRT. Distal margin length from reduced tumor by preoperative CRT to residual viable cancer, tumor grade, lymph-node-metastasis stage and pathological changes of tumors were examined., Results: Length from anal side edge of reduced tumor by preoperative CRT to pathological residual tumor ranged from +6 mm to -9 mm. Tumor stages were as follows: T0-2, N0, M0=3, T3, N0, M0=5, T4, N0, M0=1 and T3, N0, M+1=2. Median follow-up was 19 months. Recurrence occurred in one patient and was distant and not local. Pathological examinations showed that no patient had lymph-node-metastasis and residual tumors by preoperative CRT., Conclusions: This study suggests that for patients with locally advanced rectal cancer undergoing resection and preoperative CRT, distal margins ≥1 cm from reduced tumor by preoperative CRT seem to compromise pathological outcome.

Background/aims: The impact of pegylated-interferon (PEG-IFN) α-2b on liver regeneration has not yet been elucidated., Methodology: Rats were divided into the following four groups: 70% hepatectomy (Hx); 70% Hx+PEG-IFN; 90% Hx and 90% Hx+PEG-IFN group (n=6 each). Rats were pretreated with subcutaneous of PEGIFN α-2b (1.5 μg/kg) administration 24 hours before Hx. Samples were taken 24, 48 and 72 hours after Hx and the following parameters were investigated: blood analysis (AST, WBC, PLT); liver weight to body weight ratio (Lw/Bw ratio); survival and PCNA labeling index (LI)., Results: In the 90% Hx model, there was no significant difference between the Hx+PEG-IFN group and the Hx alone group in blood analysis; AST after postoperative 24 hours (2511 vs. 2466 IU/L), WBC (1200 vs. 1290) and PLT (107 vs. 111 x 10⁴/mm³), in Lw/Bw ratio at postoperative 0, 24, 48, 72 hours, respectively (0.38, 0.60, 1.14, 1.69 vs. 0.37, 0.64, 1.12, 1.63), in postoperative survival (40% vs. 45%), and in PCNA LI at postoperative 0, 24, 48, 72 hours, respectively (10.4%, 16.8%, 14.6%, 12.8% vs. 10.0%, 17.1%, 15.6%, 13.7%). In the 70% Hx model, there was no significant difference between the Hx+PEG-IFN group and the Hx alone group for all parameters., Conclusions: Our data demonstrated that PEG-IFN α-2b did not affect liver regeneration and the early use of PEG-IFN α-2b would cause no problems after liver transplantation using partial grafts including living donor liver transplantation.

Background/aims: Laparoscopic skills training is becoming the standard for educating surgical residents. Because of the specific procedure which differs from that of open surgery, it is imperative to establish a unique training system to promote efficiency of learning laparoscopic skills. The aim of this study was to evaluate the efficiency of learning laparoscopic skills with or without authorized experts of JSES., Methodology: Among 71 patients who underwent laparoscopic colectomy from 2004 to 2009, 30 patients who underwent operation in introduction era without a technical expert (2004-2006), 17 patients who underwent operation in late period of introduction era without a technical expert (2006-2008), 12 patients who underwent operation by resident with technical expert (2008-2009) and 12 patients who underwent operation by technical expert, were investigated. Operative time, amount of blood loss, intra- and post-operative complications and conversion to open surgery were investigated., Results: Operative time: 477:333:262:220 minutes (early period:late period:resident:expert), amount of blood loss: 494:73:21:20mL and complications: ileus: 0:1:0:0, leakage: 1:1:3:0, neurological disturbance: 2:1:0:0., Conclusions: Instruction by authorized technical experts of JSES is helpful to avoid pitfalls which are not seen in open surgery without an expert.

Background/aims: S-1 based chemoradiation is the recommended treatment for rectal cancer; however, the optimal scheduling and dosing are not yet established. A Phase I study was conducted to determine the maximum tolerated dose (MTD) of S-1 with radiotherapy (RT). Endpoints were the toxicity profile of this regimen and to determine the recommended dose (RD)., Methodology: Conformal RT was given using 4 fields at daily fractions of 2Gy on 5 days per week to a total dose of 40Gy. Concurrently S-1 was given twice daily throughout RT. Eligible patients had a newly diagnosed clinical stage T3-4 N0-2 M0 rectal adenocarcinoma located within 12cm of the anal verge suitable for curative resection. Surgery was performed 6 weeks from completion of preoperative chemoradiotherapy. The dose escalating from S-1 80mg/m2/day (Level 1) to 100mg/m2/day (Level 2)., Results: Nine patients were valid for safety. In all patients, S-1 was administered. There was no dose-limiting toxicity (DLT) in patients treated at dose Level 1. Six patients were enrolled in the dose-escalation phase. At dose Level 2, two patients developed DLT and this was considered the MTD. Objective response according to RECIST were observed in 5 of 9 patients who had measurable disease (56%)., Conclusions: The RD of S-1 with concurrent RT was determined to be 80mg/m2/day. Preoperative RT combined with S-1 was feasible and well tolerated.

Background/aims: Chemo-radiation therapy (CRT) has been used to improve local control and survival in patients with advanced rectal carcinoma. However, a significant proportion of patients shows poor response to adjuvant CRT. We thus investigated the usefulness of RAD51 expressions as a predictive maker of the CRT response., Methodology: Forty two patients who suffered from lower rectal cancer were investigated. All patients received preoperative CRT consisting of TS-1, concurrent with 40Gy of pelvic irradiation before having curative radical resection. The relationship between pathological responses of the tumors after therapy and expression of RAD51 was evaluated by immunostaining of resected specimen., Results: Positive expression of RAD51 was observed in 24 of 42 patients (57.1%). RAD51 positively expressed in 68.2% (15 of 22 cases) of SD and 42.2% (9 of 20 cases) of PR and CR. There is a tendency of reverse correlation between clinical response and expression of RAD51. Regarding the correlation between pathological response and RAD51 expression, positive expression of RAD51 was recognized in 75.0% (15 of 20 cases) of Grade 1, 47.1% (8 of 17 cases) of Grade 2 and 20.0% (1 of 5 cases) of Grade 3. A significant reverse correlation was recognized between RAD51 expression and pathological responses., Conclusions: RAD51 expression could be one of the most important predictive factors of preoperative CRT for advanced lower rectal cancer.

Background/aims: The role of intratumoral thymidylate synthase (TS) mRNA or protein expression is still controversial and little has been reported regarding relation of them in colorectal cancer., Methodology: Forty-six patients with advanced colorectal cancer who underwent surgical resection were included. TS mRNA expression was determined by the Danenberg tumor profile method based on laser-captured micro-dissection of the tumor cells. TS protein expression was evaluated using immunohistochemical staining., Results: TS mRNA expression tended to relate TS protein expression. Statistical significance was not found in overall survival between the TS mRNA high group and low group regardless of performing adjuvant chemotherapy. The overall survival in the TS protein negative group was significantly higher than that in positive group in all and the patients without adjuvant chemotherapy. Multivariate analysis showed TS protein expression was as an independent prognostic factor., Conclusions: TS protein expression tends to be related TS mRNA expression and is an independent prognostic factor in advanced colorectal cancer.

Hemophagocytic syndrome (HPS) is a rare but serious complication that is associated with hypercytokinemia caused by activated T lymphocytes and macrophages in immunologically compromised patients. Living donor liver transplantation (LDLT) between adults has been performed to compensate for the shortage of available organs. There have been some reports of HPS after LDLT but its prognosis is disappointingly poor. Herein, we report a case of HPS in a 53-year-old woman who underwent LDLT using a left lobe graft. HPS was diagnosed on postoperative day 6 and successfully treated with a steroid pulse. HPS is a fatal complication in immunologically compromised patients but its early diagnosis and appropriate treatment can lead to an improved outcome.

The use of steatotic livers for transplantation is often associated with increased primary non-function. To reduce the risk of liver injury, steatosis of the donor liver in living donor liver transplantation (LDLT) was treated with restricted diet and exercise. A 21-year-old male donor, 167cm in height and 87kg in body weight, initially received a 1800kcal/day diet for 9 days which was then gradually reduced using a 1600kcal/day diet for 43 days, followed by a 1500kcal/day diet for one day and was finally maintained on a 1400kcal/day diet for 52 days. Daily exercise consumed 500kcal/day. The non-protein respiratory quotient (npRQ) gradually increased while the non-esterified fatty acids (NEFA) decreased during the course of the 105-day treatment. Consequently, the initial 80% steatosis was reduced to 10% and was accompanied by 13% weight loss for 81 days. The npRQ values and NEFA concentrations in the later period of dietary and exercise treatment were higher and lower, respectively, than in the early treatment period, indicating compensation through long-term treatment. Therefore, energy metabolism and NEFA levels represent important biomarkers for short-term intensive treatment by restricted diet and exercise in donors with hepatic steatosis.

Background/aims: Aluminum potassium sulfate and tannic acid (ALTA) is a new sclerosing therapy for internal hemorrhoids. This injection therapy is a four-step direct injection sclerosing procedure intended to shrink and harden internal hemorrhoids to eliminate hemorrhoidal prolapse and bleeding. The aim of this study was to assess the short term efficacy of this treatment., Methodology: The procedure was conducted using a four-step injection process under perianal local anesthesia. The entry point for the four-step injection of ALTA is the submucosa of the superior pole, the submucosa in the central part, the mucous lamina propria in the central part and the submucosa at the inferior pole of hemorrhoid., Results: From January 2009 to March 2010, we performed the ALTA sclerosing therapy on 28 patients (14 men and 14 women; mean age, 64.6 years), including 5 second-degree, 16 third-degree and 7 fourth-degree hemorrhoids. There were 6 postoperative complications (2 cases of low grade fever, 2 anal pains, 1 necrosis at injection site and 1 perianal dermatitis). All symptoms of prolapse or bleeding disappeared after 29 postoperative days. There were 3 recurrent cases (10.7%)., Conclusions: ALTA sclerosing therapy is a useful and less invasive treatment for internal hemorrhoids.

Background/aims: Billroth-I and Roux-en-Y procedures have been applied generally as reconstruction techniques after distal gastrectomy. There have been few reports regarding the physiological differences of these two procedures. We compared gastric emptying after Roux-en-Y procedure with the Billroth-I procedure using the 13C-acetate breath test., Methodology: Eleven patients who underwent distal gastrectomy, using reconstruction procedures of Billroth- I (B-I group: n=7) and Roux-en-Y (R-Y group: n=6), and 4 healthy volunteers (Control group) were studied. After ingestion of 200mL of liquid diet labelled with 100mg 13C-acetate, breath samples were collected every 5-15 minutes for 3 hours. The analysis of 13C-acetate enrichment was measured using infrared spectrometer., Results: Mean breath-Tmax of B-I group (14.2min) and R-Y group (13.0min) were significantly shorter compared with that of the control group (42.5min). Mean breath-T1/2 of B-I group (76.8min) and R-Y group (80.2min) were significantly shorter compared with that of the control group (133.3min). Mean breath-Cmax of B-I group (60.1min) and R-Y group (59.3min) were significantly higher than that of the control group (27.6min)., Conclusions: 13C-acetate breath test was useful to evaluate gastric emptying. There were no differences in gastric emptying for both Billroth-I and Roux-en-Y reconstruction.

Background/aims: Intrahepatic cholangiocarcinoma (IHCC) is known to be one of the most malignant tumors. Hypoxia-inducible factor-1 (HIF-1) is a transcription factor, which plays a central role in biologic processes under hypoxic conditions. The aim of this study was to elucidate the role of HIF-1 in IHCC., Methodology: Thirty-five patients with IHCC who underwent hepatic resection were enrolled in this study. The expression of HIF-1a was determined immunohistochemically and the patients were divided into two groups: HIF-1a positive group (n=22) and HIF-1a negative group (n=13). Clinicopathological variables including prognosis were compared between the two groups. The prognostic factors were investigated by multivariate analysis using Cox's proportional hazard model., Results: HIF-1a expression correlated significantly with higher stage, and tended to correlate with tumor diameter (>4cm), vessels infiltration and intrahepatic metastasis. The prognosis in HIF-1a positive group was poorer than that in HIF-1a negative group (5-year survival: 62.9% vs. 18.3%). Furthermore, HIF-1a positive expression was identified as an independent prognostic factor for both overall and disease free survival., Conclusions: The findings suggested that the intratumoral HIF-1a regulated malignant behavior and was a new prognostic indicator of IHCC.

In gastrointestinal laparoscopic surgery, paraaortic lymphadenectomy is usually performed using a transperitoneal approach (TP), and the use of an extraperitoneal approach (EP) has been scarcely reported. Biopsy of the para-aortic lymph nodes was performed using TP with 3 ports on the patient with esophageal cancer, and EP lymphnode biopsy was performed with 4 ports with malignant lymphoma. The effect of TP vs. EP was evaluated regarding the intraoperative and postoperative complications. TP was difficult for massive biopsy, 1.5cm sized several lymph nodes along the common hepatic artery were biopsied. On the other hand, using EP a 5cm sized paraaortic lymph node was successfully performed. There was no difference between TP and EP in intraoperative blood loss and operation time, respectively, but EP showed great advantage with respect to postoperative complications and length of administration in hospital. Laparoscopic biopsy of para-aortic lymph nodes using EP is a useful method compared with the TP.

Background/aims: Barrett's esophagus is a major risk factor for esophageal adenocarcinoma. It is important to decide when and how to treat the patients with Barrett's esophagus (BE). It was reported that HDAC-1 (Histone Deacetylase-1) and MTA-1 (Metastasis-Associated Protein-1) were associated with initiation and progression of cancer. The aim of this study is to assess malignant potential of BE using the expression of HDAC-1 and MTA-1., Methodology: Seven BE cases with pathological specialized columnar epithelium and CK7/20 in an immunohistochemically positive state were selected from resected specimens of 23 patients with gastro-esophageal junction cancer. The expression of HDAC-1 and MTA-1 protein was evaluated using an immunohistochemical method., Results: All seven cases with Barrett's esophagus were diagnosed as low grade dysplasia. Positive expression of HDAC-1 and MTA-1 was found in 0 out of 7 cases (0%) with normal esophageal epithelium, and 0 out of 7 cases (0%) with normal gastric epithelium. On the other hand, positive expression of both HDAC-1 and MTA-1 was found in 6 out of 7 (85.7%) cases with Barrett's epithelium and 7 out of 7 (100%) cases with gastro-esophageal-junction-cancer, respectively., Conclusion: Positive expression of HDAC-1 and MTA-1 was found even in low grade dysplasia. Therefore, BE with HDAC-1 and MTA-1 expression is considered to be a precancerous lesion re quiring curative treatment.

Background: Preoperative radiological diagnosis of gastric cancer with peritoneal metastasis is still incomplete. Staging laparoscopy is performed for patients who are diagnosed T3 or T4 preoperatively. The aim of this study is to establish a method for predicting peritoneal metastasis., Methodology: 236 gastric cancer patients who were determined histologically at the final staging were studied. We evaluated whether the parameters of preoperative evaluation such as maximum tumor size, circumferential involvement, macroscopic type, number of metastatic lymph nodes and histological differentiation could predict a peritoneal metastasis., Results: The patients with maximum tumor size > 50 mm in diameter, all 4 cross-sectional parts in circumference involved, Type IV tumor, number of metastatic lymph nodes > 3 and histologically undifferentiated type had a significantly higher incidence of peritoneal metastasis, compared with those with other types. Maximum tumor size > 50 mm, all 4 cross-sectional parts involved and type IV were confirmed as independent risk factors by multivariate analysis. A predictive equation "y = 0.018+0.171 (Maximum tumor size > 50 mm)+0.387 (all 4 cross-sectional parts involved)+0.183 (type IV)" was established. When y value was set to 0.5, sensitivity and specificity were 78.3%, 88.5%, respectively., Conclusion: The predictive equation of peritoneal metastasis revealed satisfactory results and can be regarded as useful in diagnosing peritoneal metastasis.

Radiofrequency ablation (RFA) is widely used for the treatment of unresectable hepatocellular carcinoma (HCC) with cirrhosis, however, unexpected injuries to the adjacent organs remains the most critical problem after endoscopic radiofrequency ablation (RFA) using a percutaneous approach. The endoscopic RFA is a minimally invasive treatment for HCC with difficultly in the location due to limited percutaneous access. In this study, it was used an endoscopic approach or an open surgical approach for the treatment of 46 patients with unresectable HCC. There was difficulty in ablating the lesions due to limited percutaneous access. The endoscopic approach was assessed for 26 patients with primary HCC, and the open approach was used for 18 patients of recurrent HCC after surgical resection as well as the other 2 patients with multiple HCCs. The endoscopic RFA was performed using a laparoscopic approach for 20 cases and a thoracoscopic approach for 6 cases. The endoscopic RFA had significantly less intraoperative blood loss compared to the open RFA (56 g vs. 277 g; p < 0.001) as well as a reduced postoperative hospital stay (13 days vs. 16 days; p < 0.05). The occurrence of postoperative complications did not different between the two groups; 5 of 26 cases of the endoscopic RFA, and in 3 of 20 cases of the open RFA. The local recurrence of HCC occurred in only 1 case for each group, and the patient survival did not differ significantly between the groups. Endoscopic RFA is a feasible and reliable therapy for unresectable primary HCCs in the patients with cirrhosis.

Background/aims: It has not determined whether post-transplant persistent hypersplenism (PTPH) occurs after living donor liver transplantation (LDLT)., Methodology: One hundred and ninety-four patients who survived more than 6 months after LDLTs were examined for the evaluation to determine the incidence of PTPH (leukocyte counts <3,500/microL and/or platelet counts <7.5 x 10(4)/microL). In addition, 154 patients without a splenectomy were evaluated for the risk factors for PTPH., Results: The incidence of PTPH was 20.1% (n=31/154), and the occurrence ranged between 1.1 and 9.9 years after the LDLT, with the mean follow-up periods of 3.3+/-2.5 years. Multivariate analysis showed that portal pressure >30 mmHg at the time of the laparotomy (p<0.01) and post-LDLT small for size syndrome (p<0.01) are risk factors for PTPH. For those with severe portal hypertension (>30 mmHg at laparotomy), the splenectomy tended to give better survival rate (p=0.09) without increasing the rate of septic complications., Conclusions: Hypersplenism did persist in a proportion of patients after LDLT. A high-risk for PTPH, especially severe portal hypertension, may be an indication for a splenectomy during LDLT in order to achieve uncomplicated post-transplant recovery.

Background/aims: Advanced biliary carcinoma have poor prognosis and chemotherapy has been shown to have little impact. The aim of the present study is to clarify the effectiveness of GEM combined with CDDP and 5FU (GFP) therapy for unresectable biliary carcinoma., Methodology: Fourteen patients with biliary carcinoma (4 patients; gallbladder cancer, 10 patients; biliary tract) who had no prior chemotherapy were enrolled. A triple combination of agents was administered with a 4-week cycle GFP chemotherapy consisting of GEM at 1000 mg/m2 on days 1 and of 5-FU at 250 mg/m2 and CDDP at 3mg/m2 on days 1 to 5., Results: No patient achieved CR, while five patients achieved PR as assessed by RECIST. The overall response rate from the intent-to-treat analysis was 21.4%. Stable disease was observed in 9 (64.3%) patients. Clinical benefit rate was observed in 14 (85.7%) patients. According to the tumor site, overall response rate was 20.0% in biliary tract carcinoma, on the other hand, 25.0% in gallbladder carcinoma., Conclusions: The significant antitumor activity of GFP chemotherapy has been seen in patients with advanced biliary carcinoma. However, further evaluation in large numbers of patients is needed to determine the difference in chemosensitivity according to the tumor site.

A clinicopathological analysis of a case with long-term survival after surgical resection for hepatocellular carcinoma (HCC) with massive bile duct tumor thrombus (BDTT) is presented. A 73-year-old female, who was hepatitis C antibody-positive, was referred to our hospital for jaundice. She had a history of small HCC in segment 4 of the liver, which was treated by percutaneous ethanol injection therapy 5 years previously. Contrast-enhanced magnetic resonance imaging detected the primary tumor in segment 4, and a BDTT in the common bile duct with dilatation of the intrahepatic bile duct. Percutaneous transhepatic cholangiography revealed a defect from the bilateral hepatic ducts to the middle part of the common bile duct. Left lobectomy of the liver with thrombectomy and local bile duct resection was performed. The patient has remained alive with no sign of recurrence for 5 years since the surgery. Here, we describe this case of HCC with BDTT showing long-term survival and the usefulness of curative surgical resection with removal of the tumor thrombus.

Background/aims: The postoperative survival rate is dependent on the invasive depth of the gallbladder carcinoma. When this carcinoma has invaded beyond the subserosal layer, lymph node and adjacent organ involvement is found in a large number of patients, and long-term survival cannot be achieved. The aim of this study is to establish a surgical strategy for advanced gallbladder carcinoma according to the invasive depth., Methodology: A retrospective analysis was conducted of 44 patients with the gallblader carcinoma. The invasive depth was histologically defined by the Japanese Society of Biliary Surgery system as follows. (hinf0: within muscle layer, hinf1a: subserosal layer, hinf1b: hepatic infiltration within 5 mm, hinf2.3: hepatic infiltration more than 5 mm), Results: Wedge resection of the gallbladder bed was performed in 5 cases, and in four of the five patients (80%), intrahepatic recurrence occurred within 6 months. S4a+S5 subsegmentectomy of the liver is performed in 11 cases (hinf0,1a/b:n=5, hinf2,3:n=6) and the postoperative survival rate was significantly better in cases of hinf0,1a/b (p<0.05). In cases of hinf2,3 an extended hepatic lobectomy (n=5) tended to obtain a better survival rate, compared with S4a+S5 subsegmentectomy (n=6)(p=0.13)., Conclusions: S4a+S5 subsegmentectomy of the liver is a standard operation for GB carcinoma with subserosal invasion.

The rate of de novo hepatitis B infection, after liver transplantation from a hepatitis B core antibody (HBcAb) (+) donor to a surface antibody (HBsAb) (+) recipient has not yet elucidated. Four recipients with HBsAb (+) and HBcAb (+), who received living donor grafts from HBcAb (+) donors were herein reviewed. They received lamivudine monotherapy: three patients with HBsAb titer >10 IU/L did not demonstrate the onset of HBsAg, whereas one patient with HBsAb titer <10 IU/L developed hepatitis B antigen (HBsAg) 4 years after transplantation. An HBsAb (+) patient with a titer of >10 IU/L is therefore considered not to require combination therapy when receiving an HBcAb (+) liver graft. However, a great deal of caution is necessary in patients with negative or low HBsAb titers <10 IU/L.

Spontaneous regression of a malignant tumor, including hepatocellular carcinoma, is extremely rare. A 78-year-old female with hepatitis B presented with a hepatocellular carcinoma, 3 cm in size, in the lateral segment. During her work-up before surgery, over the period of a month, the tumor started to show spontaneous regression from the radiological and biochemical studies. A lateral segmentectomy of the liver was performed, and the pathologic study showed complete necrosis of the tumor with vigorous inflammatory cellular infiltration. The patient is now doing well without any evidence of recurrence. We herein report a case with hepatocellular carcinoma showing spontaneous regression, and review the associated literature.

A spontaneous retroperitoneal bleeding and hematoma is among uncommon disease processes, which might result in sudden circulatory collapse. A 63-year-old female, the day after liver transplantation, had sudden circulatory collapse with abdominal pain. An immediate surgical management, instead of radiological intervention, was performed with a successful outcome. This paper provides an outline of the diagnosis and treatment in a case of spontaneous retroperitoneal hemorrhage, which developed after living-donor liver transplantation.

Background/aims: To evaluate the efficacy of a jejunal pouch after a total gastrectomy with Roux-en Y reconstruction., Methodology: Thirty patients with gastric cancer who had a total gastrectomy as a radical operation and had no recurrence were enrolled in this study. The jejunal pouch was added to Roux-en Y reconstruction in 15 patients (J-pouch group) and was not added in the other 15 patients (Roux en-Y group). A questionnaire survey which consisted of dietary intake, postprandial abdominal complaints and body weight, blood examination (hemoglobin, total protein, albumin), were conducted. The 99mTc-DTPA with semi-liquid diet emptying test and the manometry in the jejunal pouch were evaluated in 12, 2 of the J-pouch group, respectively., Results: There were no significant differences between the two groups in the questionnaire survey and blood examination. The half emptying time (T1/2) of 99mTc-DTPA was over 60 minutes in 9 of the 12 J-pouch group. The manometric study did not reveal the effective contraction of the jejunal pouch. Bypass operation was necessary due to marked delay of emptying in the jejunal pouch for one patient in the J-pouch group., Conclusions: The advantage of adding a jejunal pouch to Roux en-Y reconstruction was not proven in this study.

Background/aims: Left lobe graft is an ideal option to minimize potential risk for the donor in adult living-donor liver transplantation (LDLT). However, its use is restricted due to size limitations. The purpose of this study was to determine the impact of a new technique for the acquisition of additional liver volume for left lobe graft., Methodology: Three donors underwent left hepatic lobectomy by exploiting a new technique as follows: a demarcation line was marked by clamping the right first Glisson's pedicle. A parenchymal transection plane was located 1 cm right side from the demarcation line and just on the left side of the right anterior Glisson's pedicle. A part of the anterior segment added to the left lobe graft by this procedure belonged to right anterior segment by preoperative CT. The preoperative volumetry of the liver was performed using the 3D-CT software, which was able to calculate total liver volume and the volume of each vessel's territories. Additional liver volume was calculated by preoperative CT scan and defined as part of the perfusion area by the right anterior portal branch. Blood perfusion of the additional liver area was postoperatively assessed by dynamic CT, and graft outcome was also evaluated., Results: An additional gain ranged from 40 mL to 51 mL (mean 41.8 mL). GV/SLV was 35.7, 60.0, and 41.0%. The rate of additional volume in GV/SLV ranged from 7.2-8.4% (mean 7.6%). All grafts functioned well. The CT scan performed on early postoperative period confirmed excellent blood perfusion the additional segment. No complication attributable to small-for-size graft was noted., Conclusions: This new technique for left lobe graft harvesting proved a promising approach to gain additional volume, thereby avoiding small-for-size graft in adult LDLT.

Background/aims: Clinicopathologic characteristics and postoperative prognosis of early hepatocellular carcinoma (eHCC) have not been clarified., Methodology: Early HCC was designated as tumor purely composed of well-differentiated HCC not containing moderately or poorly differentiated component. Twenty seven patients with early HCC among 515 patients underwent hepatic resection for HCC were analyzed., Results: The survival rate at 5 years after hepatic resection of the patients with early HCC was 76%. No clinicopathologic factors correlated with the survival. The postoperative recurrence occurred in 19 (70%) patients, and nine patients survived more than five years free of recurrence. The levels of aspartate aminotransferase and alanine aminotransferase of the patients with recurrence within five years (n = 9) were much higher than those of the patients without recurrence (n = 18). The prognosis after recurrence of the patients with more than three tumors was significantly worse than that of the patients with one or two tumors (P < 0.01)., Conclusions: The survival rate of early HCC after hepatic resection is favorable, however, recurrence is considerably frequent and it depends on the degree of inflammation of underling liver disease. Therefore, the control of inflammation of liver parenchyma and the preservation of liver function may be most important in patients with early HCC.

Background/aims: Des-gamma-carboxyprothrombin (DCP), is a well-known tumor marker of hepatocellular carcinoma (HCC). On the other hand, some reports suggest that tissue expression of DCP is more useful as a prognostic factor than the serum DCP value. The aim of this study is to clarify the clinicopathological role of expression of DCP on HCC, especially when there is a low serum level of DCP., Methodology: Fifty-one patients with HCC who underwent curative hepatectomy were included in this study. Immunohistochemical staining was performed using anti-DCP monoclonal antibody, which was classified into 2 groups (strong and weak) by a pathologist. The immunohistochemical expression of tumor microvessel density (MVD) was evaluated using CD34 monoclonal antibody, and counted with specific staining of the capillary-like vessels in the tumor. The clinicopathological variables were compared between the strong and weak-staining groups., Results: A strong DCP expression was recognized in 31 patients. DCP expression was associated with tumor size (p < 0.05) and portal vein infiltration (p < 0.01). In addition, serum DCP levels and alpha-fetoprotein levels tended to be higher in the strong group. In 16 patients whose serum DCP level was < 200mAU/ml, the recurrence-free survival rate was significantly lower in the strong group. No correlation was observed between DCP expression and MVD., Conclusions: DCP expression in HCC is useful for the prediction of early recurrence in patients with a low serum DCP level.

This paper reports a rare case of intrahepatic cholangiocarcinoma (ICC) which recurred nine years after surgical resection. The patient underwent right hepatic trisegmentectomy with lymph node dissection and biliary tract reconstruction for a tumor in the right lobe of the liver. The patient was diagnosed with ICC, intraductal growth (IG) type. Nine years after the operation a rise of tumor markers and a recurrent lesion in the remnant liver were recognized and the patient underwent S2 subsegmentectomy with tumor thrombectomy and biliary tract reconstruction. The resected specimen showed well differentiated adenocarcinoma, which consisted of chiefly intraductal growth component. The patient is still alive 26 months after the second operation without recurrence. It is important to observe the patient carefully cosidering that it is possible for an IG type cholangiocarcinoma to recur a long time after surgical treatment, and surgical treatment for the recurrent tumor should be tried for long survival.

Hemophagocytic syndrome (HPS) is a hematological disorder caused by activated T lymphocytes, which leads to the proliferation of stimulated macrophages that phagocytose and destroy circulating blood elements and their precursors within bone marrow, and lead to the further production of inflammatory cytokines. Living donor liver transplantation (LDLT) between adults has been performed to compensate for the shortage of available organs. There have been some reports concerning HPS after LDLT; however, its prognosis is disappointingly poor. In particular, there is no report of treated HPS developed after LDLT using small-for-size left lobe grafts. We herein report a case of HPS in a 63-year old woman who underwent LDLT using left lobe graft weighing only 330g. The HPS was diagnosed on postoperative day 13, and was successfully treated using a combination of intravenous immunoglobulin, granulocyte colony stimulating factor, conversion of calcineurin inhibitor and steroid pulse. The trigger of HPS may not only be systemic infection, but also hypercytokinemia caused by various factors. HPS is a fatal complication in immunologically compromised patients; however, early and accurate diagnosis could lead to an adequate treatment and improve the outcome.

To date, the need for spontaneous portosystemic shunt division during adult-to-adult living donor liver transplantation (LDLT) remains unknown. This study reports 2 patients with large portosystemic shunts who required LDLT. The first patient was a 40-year-old male with liver cirrhosis due to hepatitis C. The angiogram showed splenosystemic shunts with hepatopetal flow. Shunt occlusion was not performed after implanting a small-size graft because sufficient portal blood flow was observed. On the first postoperative day, portal blood flow was not detected; therefore shunt occlusion was per formed and the portal blood flow was restored. The second patient was a 51-year-old female with primary biliary cirrhosis. Marked collateral circulation with hepatofugal flow was observed. Shunt occlusion was performed after implanting a medium-size graft. Postsurgery, hepatopetal portal blood flow was observed and the postoperative course was satisfactory. These cases demonstrate that large portosystemic shunts should be ligated to maintain adequate portal blood flow that corresponds to the graft volume.

Background/aims: In cadaveric liver transplantation, it has been reported that elderly recipients over 60 years are at risk because of high incidence of complication and malignancy. However, in living-donor adult liver transplantation (LDALT), it is unclear whether the elderly recipient is risky or not risky. In this study, the outcome after LDALT of elderly patients has been evaluated., Methodology: One hundred twenty two consecutive LDALT recipients were studied. The recipients were divided into an elderly group (older than 60 yrs, n = 21), and a control group (younger than 60 yrs, n = 101). Comparative examination of background factors, postoperative complications and de novo malignancy was carried out., Results: Elderly patients more frequently received transplantation for hepatocellular carcinoma. Pretransplant liver damage such as Child-Pugh, MELD or bilirubin level was same among the groups. There was no significant difference in posttransplant complications except renal failure. Postoperative renal failure (postoperative creatinine level over 2mg/dL) occurred in 29% (n = 5) of the elderly group vs. 8% (n = 6) of the control group. De novo malignancy occurred in 1 case (lung) in the elderly group and 1 case (Vater) in the control group. In the control group, the 1, 3 and 5 year patient survival rates were 78.5%, 73.1% and 71.4%, respectively. And in the elderly group, the 1, 3 and 5 year patient survival rates were 85.7%, 81.0% and 70.8%, respectively., Conclusions: It may be, we concluded that living donor adult liver transplantation is good treatment for end stage liver diseases in elderly recipients over 60 years. However caution should be taken in the administration of medicine, including immunosuppressants or antibiotics, do to a propensity for postoperative renal failure in elderly recipients.