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Background/aims: Vitamin E is one of the most promising treatments for non-alcoholic steatohepatitis (NASH). However, the long-term efficacy of this treatment remains unknown., Methodology: We retrospectively examined 17 patients with biopsy-proven NASH who received vitamin E at a dose of 300 mg/day for >=2 yr, and underwent second liver biopsies after treatment. Variables were compared between patients with (group R) and without (group NR) fibrosis regression., Results: The median interval between basal and second liver biopsies was 2.4 yr (range, 2.0-5.8 yr). Overall, transaminase activities, insulin resistance index, and hepatic fibrosis markers were significantly improved. Although histological steatosis, inflammation, and fibrosis did not change after treatment, liver fibrosis improved in seven patients (41.2%), progressed in five (29.4%), and remained unchanged in five (29.4%). At baseline, subjects in group R (n = 7) were more likely to have diabetes, insulin resistance, and severe fibrosis compared to those in group NR (n = 10). Lower NAFLD activity score and larger decrease of ALT and insulin resistance after treatment were observed in group R compared with group NR., Conclusions: Two years or longer treatment can be expected to ameliorate NASH fibrosis, especially in those whose serum transaminase activities and insulin resistance can be improved.

Background/aims: Pylorus-preserving pancreaticoduodenectomy (PPPD) has the advantage of achieving good nutritional status postoperatively, but delayed gastric empty (DGE) is a frequent complication leading to a longer fasting period. Subtotal stomach-preserving pancreaticoduodenectomy (SSPPD) is an alternative option to preserve nutritional status and shorten the fasting period. We retrospectively compared clinical results between PPPD and SSPPD., Methodology: PPPD was performed in 28 patients and SSPPD in 27, between 2000 and 2009., Results: Pancreatic carcinoma was more frequent in the SSPPD group (p = 0.041). Operating time was longer in the SSPPD group (610 min) than in the PPPD group (540 min; p = 0.031). Blood loss was greater in the SSPPD group (1810 mL) than in the PPPD group (1306 mL; p = 0.048). Period of NG intubation and fasting period were shorter in the SSPPD group (6 days and 9 days, respectively) compared to the PPPD group (15 days and 19 days, respectively; p <0.01 each). Severe DGE was 7% in the SSPPD group and 46% in the PPPD group (p <0.01). Postoperative complications and nutritional status in the early period did not differ between groups, although incidence of fatty liver was higher in the SSPPD group (78%) than in the PPPD group (25%; p <0.01)., Conclusions: SSPPD is a useful alternative for pancreaticoduodenectomy. Further prospective studies with longer follow-up are warranted to clarify the superiority and problems associated with this procedure.

To achieve complete resection of metastatic colonic carcinoma in the liver and lung, thoracolaparotomy-assisted simultaneous resection was attempted in a 60-year-old male patient who had previously undergone sigmoidectomy for primary sigmoid colon carcinoma. A solitary liver metastasis was observed in segment 7 and a solitary lung metastasis was located in segment 6 of the right lower lung. Simultaneous resection was attempted and, in the left lateral position, a thoraco-laparotomy with oblique incision was made in the right seventh intercostal space. Both tumors could be palpated under a good operative view. A partial hepatectomy was performed followed by a segmental resection of the lung. A chest drainage tube was inserted for two postoperative days. The patient had no remarkable complications including pulmonary complication after surgery and was discharged at day 20 post-operation. For metastatic tumors simultaneously located in the right subphrenic part of the liver and the lower part of the right lung, thoraco-laparoscopy-assisted complete resection is a safe and useful option to achieve curative treatment.

Background/aims: A new prognostic staging system, the SLiDe (S, stage; Li, liver damage; De, des-gamma-carboxy prothrombin) score was recently proposed. We examined 207 HCC patients following hepatic resection to determine the usefulness of this staging system for HCC patients after surgery., Methodology: Disease-free and overall survival rates were calculated according to the Kaplan-Meier method, and differences between groups were tested for significance using the log-rank test., Results: Regarding disease-free survival, there were no significant differences in survival between SLiDe score 0 vs 1, between score 2 vs 3, and between score 4 vs 5. There were significant differences between 0-1 vs 2-3 (p < 0.01) and between 2-3 vs 4-5 (p < 0.01). Regarding overall survival, there were no significant differences in survival between score 0 vs 1, between score 2 vs 3, and between score 4 vs 5. There were significant differences between 0-1 vs 2-3 (p < 0.05) and between 2-3 vs 4-5 (p < 0.01)., Conclusions: The SLiDe score, a staging system that combines tumor factors, a tumor marker and hepatic function, might be a better predictor of prognosis in HCC patients who have undergone hepatic resection.

Hepatocellular carcinoma (HCC) patients often have esophagogastric varices due to portal hypertension by chronic hepatitis or cirrhosis. Surgical treatment for gastric varices is necessary when the patient undergoes hepatic resection for HCC, simultaneously. We examined the clinical demographics, surgical records and outcome in 7 patients undergoing both hepatectomy and Hassab's operation (=decongestion of upper gastric veins and splenectomy) between 1994 and 2007. All patients had HCC, including chronic injured liver diseases. Preoperative liver functions were well preserved in all patients. Right hepatectomy was performed in two patients and limited resections in 5. Three patients had postoperative complications and the in-hospital death by hepatic failure was observed in one. Four patients had tumor recurrence within one year and 3 were dead, while, two patients had long-term survival with or without recurrence of HCC. Following Hassab's operation, gastric varices dramatically disappeared. Portal hypertension and hypersplenism were significantly improved. Simultaneous operation with Hassab's procedure and hepatectomy is useful and can be safely performed in HCC patients with gastric varices.

A C-arm equipped with a flat detector CT (C-arm CT) has been developed, which provides images with high spatial resolution that could facilitate effective 3D information during interventional procedures. The cone beam reconstructive method was applied for reconstruction of images. Time of reconstruction of 3D images was approximately one minute after the scan. The axial thin-slice images, the real-time volume rendering, maximum intensity projection, shaded surface display and multiplanner reconstruction images could be obtained from any direction in a single scan. We experienced 7 cases and present two informative cases with biliary obstruction caused by tumor that underwent C-arm CT. The First case shows gallbladder carcinoma invading the hilum. The C-arm CT provided precise images of the stenotic bile ducts that could be viewed in any direction. Multiple expandable metallic stent could be accurately placed in 3 stenotic bile ducts. The second case shows a hilar bile duct carcinoma. By using various pressure infusion of the contrast medium, severely stenotic hepatic duct was confirmed before surgery. C-arm CT provided useful information regarding the precise 3D status of the bile duct and the extent of tumor invasion.

Background/aims: Measurement of urinary sulfated bile acid (USBA) level is a simple urine test that reflects the degree of cholestasis in newborns. The aim of this study was to clarify the clinical significances of this test for liver diseases in adults., Methodology: We examined the relationship between USBA level in a urine sample by enzymatic assay and clinical parameters and postoperative complications in 27 patients with hepatobiliary diseases who underwent surgical procedures between 2002 and 2007., Results: Mean USBA in all patients before surgery was 39.8 +/- 64.0 micromol/L (median value was 6.6). USBA level was increased in patients with cholestasis. USBA level was significantly correlated with serum total bile acid, total bilirubin level and serum hyaluronic acid level (r = 0.850, 0.602 and 0.504, respectively) (p < 0.05) and, furthermore, tended to be correlated with liver-uptake ratio (LHL15) by technetium-99m galactosyl human serum albumin (99SmTc-GSA) scintigraphy and alanine aminotransferase level (r = -0.469 and 0.436, respectively but not significant). USBA level tended to be associated with postoperative uncontrolled ascites (p = 0.050, not significant). Postoperative USBA level by day 7 was not changed; however, USBA level in patients with cholestatic diseases was decreased., Conclusions: USBA is a simple and sensitive noninvasive test for cholestasis and also useful to predict postoperative uncontrolled ascites after hepatic resections.

Background/aims: We preliminarily examined the characteristics of patients who underwent laparoscopic assisted hepatic resection (LAPH) to clarify its advantages and limitations of this procedure., Methodology: We examined the demographics, surgical records and outcome in 9 patients undergoing LAPH between 2001 and 2007 by comparing results in 15 patients (control group) who did not undergo laparoscopy before 2000., Results: By comparing the control group, patient demographics were not different. Four patients underwent left lateral sectionectomy and others underwent partial hepatectomy. One patient needed combined resection of abdominal wall and left lateral sector because of direct invasion from a liver tumor. There was no remarkable morbidity or mortality in all patients. Mean operation time in the LAPH group was significantly longer than that in the control group (356 +/- 68 vs. 276 +/- 59 minutes) (p = 0.015), particularly in patients undergoing partial resection. Blood loss was not different between groups. Days of use of pain reliever and hospital stay in the LAPH group was significantly shorter than that in the control group (p < 0.001). These tendencies were similar in each operative procedure., Conclusions: LAPH can be safely performed even in patients with chronic liver injury and recovery of patients from operation was faster than that by conventional hepatectomy.

In anatomical resection of the liver, transection of the hepatic vein or Glisson's pedicle is necessary. We examined the surgical records and outcome of 25 patients who underwent hepatectomy. An endovascular stapler with 35 and 60 mm staples was used for transection of the hepatic vein or Glisson's pedicle, and hepatic parenchyma including vessels. Surgery included also left lateral sectorectomy in 6 patients, right lateral sectorectomy in one, right hepatectomy in 12, left hepatectomy in two and trisegmentectomy in 4. Endovascular stapling was used for transection of hepatic veins (n=25) in all patients and Glisson's pedicle (n=8). No failure of firing occurred during cutting. Injury of an aberrant bile duct occurred in one patient, but none suffered bleeding or bile leakage from the transected parts. Vascular transection using vascular stapler could be performed safely and rapidly during anatomical hepatic resection.

Background/aims: Recently, early detection of liver tumors has been possible with improvement of various imaging techniques, and practical selection of imaging is clinically necessary to distinguish metastatic liver carcinoma (MLC) from colorectal carcinoma., Methodology: We retrospectively examined the diagnostic accuracy of enhanced computed tomography (eCT) and super paramagnetic iron oxide particles magnetic resonance imaging (SPIO-MRI) for 110 MLC lesions in 47 patients who underwent hepatic resection at a single Japanese cancer institute between 2000 and 2006. Sensitivity and positive predictive value (PPV) of both imaging techniques in comparison with resected specimens were analyzed. Fourteen cases were synchronous liver metastasis, which were resected simultaneously., Results: On a per patient basis, both eCT and SPIO-MRI showed a sensitivity of 85.1% (40 of 47 patients) and PPV was 100%, respectively. On a per lesion basis, a sensitivity of SPIO-MRI (98/110 lesions; 89%) tended to be higher than that of eCT (92 of 110 lesions; 84%), but not statistically different (p=0.32). PPV of SPIO-MRI (98 of 99 lesions; 99%) was not different from that of eCT (92 of 93; 99%). Twelve lesions in 7 patients that were not detected by both imaging methods were small lesions. PPV for liver cyst and non-timorous lesions was 99% by both imaging methods. Two liver cysts could be clearly diagnosed by SPIO-MRI only., Conclusions: We found no superiority of diagnosis with SPIO-MRI, which may not be conceptually useful for preoperative screening for MLC from colorectal carcinomas. SPIO-MRI may be useful to detect non-cancerous lesions as an adjuvant diagnostic tool with eCT.

The activity of plasmin plays a critical role in the development of chronic glomerulonephritis. Thrombin-activatable fibrinolysis inhibitor (TAFI) is a potent inhibitor of plasmin generation. We hypothesized that TAFI is involved in the pathogenesis of glomerulonephritis because it inhibits plasmin generation. To demonstrate this hypothesis, we compared the development of immune complex-mediated glomerulonephritis in wild-type and TAFI-deficient mice. After six weeks of treatment with horse spleen apoferritin and lipoplysaccharide to induce glomerulonephritis, mice deficient in TAFI had significantly better renal function as shown by lower concentrations of albumin in urine and blood urea nitrogen compared to wild-type mice. In addition, the activity of plasmin and matrix metalloproteinases was significantly increased, and mesangial matrix expansion and the deposition of collagen and fibrin in kidney tissues were significantly decreased in TAFI-knockout mice as compared to their wild-type counterparts. Depletion of fibrinogen by batroxobin (Defibrase) treatment led to equalization of the renal function and the amount of collagen deposition in the kidneys of TAFI-knockout and wild-type mice with immune complex-mediated glomerulonephritis. Together these observations suggest that TAFI-mediated inhibition of plasmin generation plays a role in the pathogenesis of glomerulonephritis, and that it may constitute a novel molecular target for the therapy of this disease.

Background/aims: Intraductal papillary neoplasm of the bile duct (IPNB) represents a biliary papillary tumor mainly growing in the bile duct lumen resembling intraductal papillary mucin-producing neoplasm of the pancreas. However, its clinical spectrum and characteristics have not been fully evaluated., Methodology: To define the clinicopathologic characteristics and prognosis of IPNB patients, 6 cases of IPNB who underwent surgical resection are presented., Results: Patients were 3 males and 3 females, aged between 47 and 79 years. Five patients had histories of hepatobiliary disease. Imagery showed cystic or diffuse dilatation of the bile ducts. Tumor markers were not valuable for diagnosis. All patients underwent hemihepatectomy with or without resection of the caudate lobe or extrahepatic bile duct. Examination showed polypoid tumors in 5 cases though 1 case had no evident tumor. Mucin was observed in 3 cases. Five cases were well-differentiated adenocarcinoma and 1 had poorly differentiated adenocarcinoma. Vascular invasion was rare and lymph node metastasis was not observed. In-situ spread of carcinoma was seen along biliary mucosa in 3 cases. Five cases survived without tumor relapse for long periods but 1 died of tumor recurrence at 31 months., Conclusions: Complete resection of IPNB based on accurate preoperative assessment of tumor extension provides a good prognosis.

Anatomic resection is theoretically effective in eradicating intrahepatic metastasis of hepatocellular carcinoma (HCC). In patients who undergo a larger volume of hepatectomy or who have hepatic dysfunction, the extent of hepatectomy is limited to avoid postoperative hepatic failure. In the present case, a limited anatomic resection according to Couinaud's segment was performed because of the large volume of the right hemi-liver. A 62-year-old male was found to have a 12-cm HCC in segments 5, 6 and 7, with alcoholic liver disease. The total liver function was Child-Pugh grade A, as indocyanine green retention rate at 15 minutes (ICGR15) was 12%. The resected liver volume of right hemihepatectomy estimated by CT volumetry was 72% and the permitted resected volume based on Takasaki's formula applying ICGR15 was 65%. As the portal branches of segment 8 was free from HCC involvement and the estimated volume of segments 5, 6 and 7 was 51%, we scheduled anatomic resection of these segments to secure remnant liver function. Under Pringle's maneuver, hepatic transection on the border between right and left liver was performed and the right paramedian Glisson's pedicle was exposed in the first step. Branches of segment 5 were divided and the border between segments 5 and 8 was confirmed. Then, the right lateral sector was resected and the right hepatic vein draining segment 8 was secured. Postoperative course was satisfactory and the patient was free from tumor relapse for 16 months after hepatectomy. Under a balance between tumor location and hepatic functional reserve, anatomic resection would be necessary for the treatment of HCC patients.

Background/aims: In advanced cancers of hepatobiliary and pancreatic lesions, major vascular resection and reconstruction are necessary to accomplish curative resection, which may provide better patient outcomes., Methodology: Surgical records, morbidity and mortality, and prognosis were examined in patients with combined vascular resection. Thirty-six patients underwent 18 hepatectomies and 18 pancreatectomies., Results: In 18 patients who underwent hepatic resection, the resected vessels were the portal vein (PV) in 10, vena cava or hepatic vein in 9 and right hepatic artery (RHA) in 3. An artificial graft was used in 2 to replace the vena cava. Vascular bypass was performed in 5 patients. Morbidity was due to biliary stricture in 1 patient and adult respiratory distress syndrome in another who died during hospital stay. Fourteen (82%) had cancer recurrence, of whom 12 died of cancer, one died of other disease, and 2 survived cancer-free. The 5-year survival was 28%. In 18 patients who underwent pancreatectomy, resected vessels were PV in 18 and RHA in 1. An artificial graft was used in 3 and vascular passive bypass was performed in 6. One patient died of sepsis after total pancreatectomy during hospital stay. Eleven (64%) had cancer recurrence, of whom 11 died of cancer, 2 died of other disease, and 4 survived cancer-free. The 3-year survival was 27%., Conclusions: Complete surgical resection (R0) combined with main vascular resection could be safely performed in many patients with disease of the hepatobiliary and pancreas, which achieved longer survival in some patients even in the advanced stage.

Background/aims: Mucinous gastric carcinoma (MGC) is a rare histopathological type of gastric carcinoma, for which the clinicopathological features and prognosis remain controversial. To clarify the clinical significance of mucinous histological type in gastric cancer, we studied clinicopathological characteristics of MGC tumors and prognosis of patients., Methodology: Forty-one patients with MGC and 1,407 patients with non-mucinous gastric carcinoma (NGC) were included in the study. Tumors were evaluated against patient gender and age, tumor location, size, and macroscopic type, depth of gastric wall invasion, lymph node metastasis, liver metastasis, peritoneal dissemination, distant metastasis, stage, and operative curability., Results: Compared with NGC tumors, MGC tumors were larger, showed more serosal invasion, were associated with a higher incidence of lymph node metastasis, and peritoneal dissemination, and tended to be at a more advanced stage. However, multivariate analysis demonstrated that the mucinous histological type was neither an independent prognostic factor nor an independent risk factor for lymph node metastasis in patients with gastric cancer., Conclusions: The mucinous histological type had no influence on patient outcome or the frequency of lymph node metastasis. MGC tumors are therefore biologically similar to those in NGC.

Background/aims: An expert technique and special anatomical or physiological knowledge are needed in the field of hepatic surgery compared to other abdominal surgeries. The establishment of basic policy and operative techniques for hepatectomy and stepwise training for young hepatic surgeons are necessary., Methodology: We scheduled hepatic resection based on the indocyanine green retention rate at 15 minutes and volumetric analysis. Limited resection or preoperative portal vein embolization was often performed., Results: Between 1994 and December 2005, 338 hepatectomies were performed. Operative procedures included limited or segmental resection in 215 and hemihepatectomy or more extended hepatectomy in 123. Hyperbilirubinemia or hepatic failure after hepatectomy was observed in 15 (4%) and hospital death in 10 (3%). Although death from hepatic failure was observed in 9 of 152 (6%) between 1994 and 1999, the mortality rate has been improved since 2000 (1 of 186 [0.5%]). Senior residents start training with step by step hepatectomy from partial resection to sectionectomy. Hemi-hepatectomy for normal liver is finally permitted after technical consolidation. More complicated hepatectomy must be performed by experienced teaching surgeons., Conclusions: Competent operative techniques under experienced surgeons and the achievement of safe resection at each stage are the educational policy for hepatectomy.

Background/aims: In advanced hepatocellular carcinoma (HCC) with vascular involvement of major vessels, patients have a poor prognosis after surgical treatment., Methodology: Patient outcomes after surgical resection and the usefulness of adjuvant chemotherapy were examined in 12 patients with major hepatic vessel involvement who underwent hepatectomy with combined resection of major blood vessels., Results: The main portal vein was resected in 8 patients, the inferior vena cava in 3, hilar bile duct in 2 and hepatic artery in 1. Eleven patients underwent hemihepatectomy and 1 underwent segment 4 and 5 resection. The portal branch was repaired by venoplasty. The vena cava wall was repaired by suture closure. The hepatic artery was replaced by end-to-end anastomosis. The bile duct was repaired by Roux-en-Y hepaticojejunostomy. Although 2 patients had biliary leakage, there were no postoperative complications in 10 patients. The tumor recurrence rate was 83% in the early period and cancer death within 1 year was observed in 6 (50%), while 3 with tumor recurrence survived for more than 2 years and 2 survived without recurrence. In 233 HCC patients who underwent hepatectomy, 10 patients including 2 present cases received adjuvant chemotherapy at the time of tumor recurrence and 2 had complete responses. While in 11 patients receiving chemotherapy without resection, the response rate using Gemcitabine (66%) was higher than that using low dose Cisplatin plus 5-Fluorouracil (22%)., Conclusions: Complete surgical resection combined with main vascular resection could be safely performed in most advanced stage HCC patients and adjuvant chemotherapy in the early period after resection would be necessary, which may achieve longer survival in some patients even in the advanced stage.

Background/aims: The present study was designed to provide a systematic analysis of prognosis of patients who underwent hepatic resection for intrahepatic cholangiocarcinoma (ICC)., Methodology: Subjects were 36 consecutive ICC patients who had undergone hepatic resection between 1994 and 2005. The analyzed factors included various clinicopathological and surgical parameters, counts of microvessel stained for CD34 and expression of proliferative cell nuclear antigen., Results: The 1, 2, 3-year disease-free survival rates after surgery were 33, 18, and 0% and the 1, 3 and 5-year overall survival rates were 45, 29, and 8%. High CEA levels (> or = 10 ng/mL), excessive intraoperative blood loss (> or = 1000 mL) and presence of neighboring peritoneal dissemination were significantly associated with shorter disease-free survival (p < 0.05). High CEA levels, periductal invasion type, excessive intraoperative blood loss and non-fibrotic liver were significant factors associated with shorter overall survival (p < 0.05). Multivariate Cox proportional hazards regression model identified high CEA values, periductal invasive type, excessive intraoperative blood loss and non-fibrotic liver as significant and independent determinants of poor prognosis., Conclusions: Hepatic resection with minimal blood loss followed by close follow-up is a suitable strategy for management of ICC patients with poor prognostic factors.

Background/aims: The relative advantages of pancreaticojejunostomy and pancreaticogastrostomy after pancreaticoduodenectomy remain to be established. To clarify differences between the two procedures, we examined 66 patients who underwent PD and compared clinical and histological parameters, surgical records and patient outcomes., Methodology: In this retrospective study, subjects were divided into a pancreaticojejunostomy group (n=48) and a pancreaticogastrostomy group (n=18). Pancreaticogastrostomy and pancreaticojejunostomy were performed using invagination technique and end-to-side anastomosis, respectively., Results: There were no significant differences in patient demographics and surgical records between the two groups. Increases in serum amylase concentrations after operation were significantly greater in the pancreaticogastrostomy group (902 +/- 915 IU/L) than in the pancreaticojejunostomy group (326 +/- 761 IU/L) (p = 0.025). However, there were no significant differences in other postoperative laboratory data or complications between the two groups., Conclusions: In our study, the clinical and safety data associated with pancreaticojejunostomy and pancreaticogastrostomy procedures for anastomosis after pancreaticoduodenectomy were almost similar. Therefore, the anastomotic procedure used should depend on the surgeon's choice or the distance between the remnant stomach and pancreas.

Background/aims: Benign cystic diseases of the liver have recently been treated by non-surgical procedures; however, uncontrolled symptomatic patients often need surgical treatment. We report here our own experience of 5 patients with cystic liver diseases (CLD)., Methodology: We examined retrospectively the clinicopathological findings and outcome in 5 CLD patients who underwent surgical treatment for 12 years., Results: All patients complained of symptoms and the mean period of symptoms was 3.8 years. Two patients had perforation of cystic content. Three patients had multiple cysts in both lobes and 2 showed a solitary cyst. The mean cyst size was 13.2cm. Communication between cyst and bile duct was observed in 1 patient. Liver scintigraphy was good compared to the higher value of ICGR15 in 3 patients. Deroofing was performed in 3 patients including laparoscopic treatment and 2 underwent hemihepatectomy. The mean amount of the cystic fluid was 1560mL. All patients had benign liver cysts by histologic findings. One patient had a biloma after deroofing which was percutaneously drained and cured. Although liver cyst recurred in 2 patients, all patients have survived without severe symptoms., Conclusions: Surgical radical treatment provides good prognosis in CLD patients with uncontrolled symptoms.

Background/aims: To predict the risk of liver dysfunction associated complications after hepatectomy, we evaluated perioperative parameters in patients after hepatectomy., Methodology: We examined 185 consecutive patients who underwent hepatectomy for liver tumors. Background liver was normal liver in 73 patients, chronic viral hepatitis in 49, cirrhosis in 46 and icteric liver in 17. Postoperative complications associated liver dysfunction (long-term ascites, intraabdominal infection and hepatic failure) occurred in 70 (38%) patients., Results: Univariate analysis identified 9 significant parameters associated with postoperative complications (resected volume > or = 50%, intraoperative bleeding volume > or = 1500 mL, liver activity at 15 min by technetium-99m galactosyl human serum albumin scintigraphy of < 0.85, alanine aminotransferase > or = 80 IU/L, total cholesterol < 150 mg/dL, prothrombin activity [PT] < 80%, Liver Damage grade B, histopathological activity index [HAI] of > or = 8 and hyaluronic acid [HA] of > or = 150 ng/mL). Multivariate logistic regression analysis identified resected volume, intraoperative bleeding, PT and HA levels as four significant independent predictors of post-hepatectomy complication with odds ratios of 7.0, 4.4, 7.5, and 5.4, respectively., Conclusions: Preoperative assessment and correction of abnormal PT and HA, careful evaluation of resected volume and attempt to reduce intraoperative bleeding are important to avoid postoperative hepatic complications.

To achieve complete ablation of liver cancer in the hepatic dome, thoracoscopy-assisted radiofrequency ablation was attempted in three patients. Under general anesthesia and left lateral position, a thoracoport site was placed in the 6th intercostal space and a small thoracotomy was placed in the 7th intercostal space. In all three cases, the liver cancer was located in the hepatic dome of segment 7/8 and the tumor could not be fully observed on the lung echogram. In Case 1, saline was infused into the thoracic cavity under thoracoscopic observation and percutaneous ablation was safely performed. In Cases 2 and 3, the right diaphragm was opened, guided by ultrasonography, and the electrode was inserted into this working space via the thoracotomy site. At day 7, complete ablation was confirmed by computed tomography. All patients recovered and were discharged after a short hospital stay without severe complications. Tumor recurrence has not been observed in any patient at this stage. For liver cancer located in the right subphrenic dome of the liver, thoracoscopy-assisted ablation is a safe and useful option particularly in patients with poor hepatic function.

Background/aims: Thoracoabdominal approach might be safe and facilitate hepatic resection for tumors located in the right lobe. To evaluate the clinical usefulness of the thoracoabdominal approach using oblique incision for the right-side hepatectomy, we compared the perioperative data with those of the abdominal approach., Methodology: The oblique incision for the thoracoabdominal approach was placed along the intercostal space (Oblique group, n=13). The J-shape incision for abdominal approach consisted of an upper median incision and transverse incision (J-shape group, n=13)., Results: Patient demographics were similar in the two groups. Operation time was significantly shorter in the oblique group (292 +/- 122 min) than in the J-shape group (450 +/- 137 min, p < 0.01). The difference was noted regardless of the extent of hepatic resection. Clamping time and blood loss were similar in the two groups. The postoperative period of use of analgesia tended to be shorter in the oblique group (9 +/- 3 days) than in the J-shape group (15 +/- 11 days) but not significant (p = 0.08). Postoperative liver function tests, complications and clinical outcome were not significantly different between the two groups., Conclusions: Thoracoabdominal approach using oblique incision was useful for resection of liver tumors located in the hepatic dome and posterior segment.

Background/aims: The aim of our retrospective study was to compare the factors contributing to postoperative complications according to the extent of hepatectomy., Methodology: We examined 166 patients with hepatobiliary carcinoma who underwent hepatectomy. Patients were divided into three groups according to the type and extent of hepatectomy: 1) left lobectomy (n=27), 2) right lobectomy or posterior segmentectomy (n=55) and 3) other hepatectomies (n=84). Patient demographics, major complications (infection, ascites, pleural effusion, atelectasis, static symptoms of the stomach, biliary leakage and hepatic failure) after hepatectomy were analyzed., Results: In patients with obstructive jaundice, lobectomy was the most commonly performed operation due to the extent of tumor along the main hepatic duct. Prolonged ascites or massive pleural effusion was frequently observed after right lobectomy (p=0.001) and posterior segmentectomy (p=0.002). However, the incidences of these complications were similar in patients with chronic viral hepatitis. Symptoms related to gastric stasis and biliary leakage were significantly more common after left lobectomy than other surgeries. The incidence of hepatic failure was higher (p<0.05) after major hepatectomy, particularly right lobectomy, than other surgeries., Conclusions: Our results emphasize the need to understand characteristics of specific complications occurring after different types of hepatic resection surgery to prevent post-hepatectomy complications.

To evaluate the clinical significance of thioredoxin in diabetic patients, serum thioredoxin levels measured with a recently established sandwich enzyme-linked immunosorbent assay kit were compared with clinical laboratory data and complications in 174 patients with Type 2 diabetes. Thioredoxin levels were significantly higher in diabetic patients (mean value, 38 ng/ml) than in healthy controls (21 ng/ml) (p < 0.05). Fasting blood sugar and hemoglobin A1c did not correlate with thioredoxin. Plasma non-esterified fatty acids levels were significantly higher in patients with higher thioredoxin levels (>or= 40 ng/ml) than in those with lower thioredoxin levels (< 40 ng/ml) (p < 0.001). There was a significant correlation both between thioredoxin and non-esterified fatty acids in patients with diet/exercise therapy (p < 0.01) and between thioredoxin and fasting immunoreactive insulin in those treated with diet/exercise or oral hypoglycemic agents (p < 0.05). Thioredoxin did not correlate with diabetic complications. In conclusion, serum thioredoxin levels may reflect the status of insulin resistance in Type 2 diabetic patients.

Thickening of the basement membrane and other structural alterations of the vascular walls occur frequently in patients with diabetes. The vascular response to atrial natriuretic peptide (ANP) is also altered in these patients. Abnormal vascular response in diabetes may be due to alteration of vascular physicochemical properties induced by accumulation of components of vascular basement membrane. The aim of this study was to evaluate the relationship between circulating levels of the 7 S domain of type IV collagen (7 S-collagen), and ANP in normotensive type 2 diabetic patients with or without retinopathy. Forty-one normotensive type 2 diabetic patients (n = 19 with and n = 22 without retinopathy) and 18 age-matched control subjects participated in the study. Serum 7 S-collagen and plasma ANP levels were measured by radioimmunoassays. Serum 7 S-collagen (4.4 +/- 0.1 vs 3.5 +/- 0.1 ng/ml; p < 0.01) levels and plasma ANP (20.8 +/- 1.0 vs 15.5 +/- 1.0 pg/ml; p < 0.01) were significantly higher in diabetic patients than in normal subjects. Serum 7 S-collagen increased significantly in diabetic patients without retinopathy compared with normal subjects (4.1 +/- 0.1 vs 3.5 +/- 0.1 ng/ml; p < 0.01). Diabetic patients with retinopathy showed significantly higher circulating concentrations of 7 S-collagen (4.6 +/- 0.1 vs 4.1 +/- 0.1 ng/ml; p < 0.01) and ANP (22.9 +/- 1.4 vs 18.9 +/- 1.3 pg/ml; p < 0.05) than those without retinopathy. There was a significant and positive correlation (r = 0.51, p < 0.01) between the circulating levels of 7 S-collagen and ANP in all patients. The results of this investigation showed that increased circulating levels of ANP correlate with the abnormal metabolism of the vascular basement membrane observed in diabetic patients with microangiopathy.

Although it has been firmly established that D-glucose inhibits glucagon secretion from pancreatic A cells, the regulatory mechanism of glucagon secretion by D-glucose has not been elucidated. To study this regulatory mechanism by D-glucose, the effects of hexoses and their derivatives on glucagon secretion from the A cells of isolated perfused rat pancreas were investigated. When these cells were perfused with D-glucose, D-fructose, D-sorbitol, D-galactose, 2-deoxy-D-glucose, D-gluconic acid sodium salt and D-glucosamine HCl salt, glucagon secretion was significantly inhibited. None of the hexoses or their derivatives tested were found to stimulate glucagon secretion. The effects of these sugars on glucagon secretion were independent of their metabolism in the cells. From the findings that the sugars both metabolized and unmetabolized in the cells demonstrated comparable inhibition of glucagon secretion from the isolated perfused rat pancreas, it is speculated that the recognition system for these sugars may be probably present on the A cell membrane and responsible for mediating these inhibitory effects of glucagon secretion.