Search

The liver is the most common metastatic site of colorectal cancer. Hepatectomy is the mainstay of treatment for patients with colorectal liver metastases (CRLMs). However, there are cases of early recurrence after upfront hepatectomy alone. In selected high-risk patients, neoadjuvant chemotherapy (NAC) may improve long-term survival.To determine the efficacy of NAC for initially resectable CRLMs.Among 644 patients who underwent their first hepatectomy for CRLMs at our institution, 297 resectable cases were stratified into an upfront hepatectomy group (238 patients) and a NAC group (59 patients). Poor prognostic factors for upfront hepatectomy were identified using multivariate logistic regression analysis. Propensity score matching was used to compare clinical outcomes between the upfront hepatectomy and NAC groups, according to the number of poor prognostic factors. Survival curves were estimated using the Kaplan-Meier method and compared using the log-rank test.Preoperative carcinoembryonic antigen levels (≥ 10 ng/mL) (NAC may improve the prognosis of high-risk patients with resectable CRLMs who have two or more risk factors.

Background: The predictive factors for discontinuation of S-1 administration and prognostic factors in elderly patients with pStage II/III gastric cancer receiving S-1 adjuvant chemotherapy remain unclear. Methods: Between January 2004 and December 2016, 80 elderly gastric cancer patients (≥70 years) undergoing curative D2 gastrectomy were enrolled in this study. Predictive factors for completion of S-1 administration over 1 year, adverse events due to S-1 administration, and prognostic factors for overall survival (OS) and relapse-free survival (RFS) were evaluated. Results: Twenty-eight patients (35%) completed 8 courses of S-1. The median relative dose intensity was 82.1% (IQR 31.1–100%). The incidence rates of hematological and nonhematological adverse events were acceptable. Distal gastrectomy was an independent predictive factor for completion of S-1 administration (odds ratio [OR] 0.364; 95% confidence interval [CI] 0.141–0.939; p = 0.037). Higher postoperative neutrophil count/lymphocyte count (N/L) ratio and more advanced stage adversely influenced OS. Multivariate analysis revealed that a higher postoperative N/L ratio and more advanced stage adversely affected RFS. Conclusion: To complete adjuvant S-1 administration to elderly patients with pStage II/III gastric cancer, total gastrectomy should be avoided if possible. A new regimen for elderly gastric cancer patients with higher postoperative N/L ratios and more advanced stage should be established.

A duct-to-duct-biliary-anastomosis is the preferred biliary reconstruction technique in liver transplantation; biliary complications remain the major concerns for the technique. We examined the significance of the intramural vascular network of the extrahepatic bile duct (EBD) and its relevant vessels. We microscopically examined the axial sections of the EBD with 5 mm intervals of 10 formalin-fixed deceased livers. The luminal-areas of the 3 and 9 o'clock arteries correlated significantly and positively with the distance from the bifurcation of the right and left hepatic ducts (the 3 o'clock artery

Background/aim Prophylactic splenectomy has shown no inferiority for tumors not invading the greater curvature side. Despite this, the clinical impact of prophylactic splenectomy for proximal advanced gastric cancer is not clear. This review aimed to clarify the impact of splenectomy for advanced gastric cancer in the upper third of the stomach. Materials and methods A systematic review and meta-analysis were conducted based on PubMed and EMBASE databases. The following search terms were used: "gastric cancer" OR "splenectomy" OR upper third of the stomach" OR preservation of the spleen. Results Out of 765 articles, 18 studies (combined n=6,341) were included in the analysis. Four randomized controlled trials (RCT) and eight retrospective studies suggested the benefits of spleen-preserving gastrectomy. Six retrospective studies showed no significant benefit of spleen-preserving gastrectomy. Prophylactic splenectomy showed a close association with a higher incidence of postoperative morbidity (pancreatic fistula and anastomotic leakage) with no concomitant improvement in overall survival. Prophylactic splenectomy should not be routinely performed and RCTs are necessary to confirm the impact of splenectomy for cN(+) at the splenic hilum tumors and tumors invading the greater curvature.

Purpose: To assess the utility of measurement of the computed tomography (CT) attenuation value (CTav) in predicting tumor necrosis in hepatocellular carcinoma (HCC) patients who achieve a complete response (CR), defined using modified Response Evaluation Criteria in Solid Tumors (mRECIST), after lenvatinib treatment. Method: We compared CTav in arterial phase CT images with postoperative histopathology in four patients who underwent HCC resection after lenvatinib treatment, to determine CTav thresholds indicative of histological necrosis (N-CTav). Next, we confirmed the accuracy of the determined N-CTav in 15 cases with histopathologically proven necrosis in surgical specimens. Furthermore, the percentage of the tumor with N-CTav, i.e. the N-CTav occupancy rate, assessed using Image J software in 30 tumors in 12 patients with CR out of 571 HCC patients treated with lenvatinib, and its correlation with local recurrence following CR were examined. Results: Receiver operating characteristic (ROC) curve analysis revealed an optimal cut-off value of CTav of 30.2 HU, with 90.0% specificity and 65.0% sensitivity in discriminating between pathologically identified necrosis and degeneration, with a CTav of less than 30.2 HU indicating necrosis after lenvatinib treatment (N30-CTav). Furthermore, the optimal cut-off value of 30.6% for the N30-CTav occupancy rate by ROC analysis was a significant indicator of local recurrence following CR with 76.9% specificity and sensitivity (area under the ROC curve; 0.939), with the CR group with high N30-CTav occupancy (>30.6%) after lenvatinib treatment showing significantly lower local recurrence (8.3% at 1 year) compared with the low (30.6% might be a predictor of maintenance of CR. Use of these indicators have the potential to impact systemic chemotherapy for HCC.

Introduction: The benefits of surgery in older patients with gastric cancer are controversial. This single-institution retrospective study in Japan aimed to evaluate the impact of gastrectomy in older patients with gastric cancer. Methods: A series of 234 patients aged ≥80 years with histologically confirmed gastric cancer had indications for surgical treatment at the Gastroenterological Center, Yokohama City University Medical Center, between April 2002 and December 2018. Patients who were lost to follow-up (n = 27), had tumors not eligible for surgery (n = 14), and could not achieve R0 resection (n = 7) were excluded from this retrospective study. The remaining 186 patients were included. Patient characteristics, intraoperative outcomes, postoperative complications, and long-term survival were evaluated. Results: The incidence of postoperative complications with Clavien–Dindo grade ≥ II was observed in 61 patients (32.8%). The 5-year relapse-free survival and overall survival (OS) rates were 84.2% and 63.4%, respectively. Multivariate analysis showed that geriatric nutritional risk index (p = 0.047), neutrophil/lymphocyte ratio (>2.36) (odds ratio, 1.94; 95% confidence interval, 1.02–3.67; p = 0.043), and total gastrectomy (TG) (odds ratio, 1.97; p = 0.042) significantly predicted postoperative complications. Moreover, TG (hazard ratio, 1.91; p = 0.036) was an independent prognostic factor of OS. Conclusions: Poor immunonutritional status and TG led to worse short-term outcomes. Moreover, TG was an independent prognostic factor of OS in older patients with gastric cancer. It is necessary to provide effective perioperative care, including nutritional support, to clarify whether short-term outcomes would be improved.

Background Although endoscopic interventions for chronic pancreatitis are highly developed, surgery for severe complicated cases such as the coexistence of bile duct, duodenum, and portal vein stenosis is a challenging issue for surgeons. In such instances, pancreaticoduodenectomy could lead to massive intraoperative bleeding due to severe collateral veins. A surgical drainage procedure, instead of pancreatic resection, may be a reasonable and safer option in such cases, but the literature on a surgical drainage technique to resolve all obstructions of the pancreatic duct, bile duct, and duodenum at once is limited. We devised a new surgical drainage method for such cases with consideration for a possible future second surgery for newly developed pancreatic cancer because chronic pancreatitis is a well-known high-risk factor for pancreatic cancer in the long term. Here, we report this surgical procedure. Case presentation A 55-year-old man was diagnosed with alcoholic chronic pancreatitis 15 years ago. Before surgery, he underwent regular endoscopic pancreatic stenting for pancreatic ductal stenosis for 3 years. Three months before surgery, his duodenal stenosis worsened, and he was referred to our department for surgery. Preoperative imaging revealed pancreatic and bile duct stenosis, duodenal stenosis, and portal vein stenosis. To avoid intraoperative bleeding caused by the development of collateral veins, we performed a triple drainage procedure: longitudinal pancreaticojejunostomy with coring-out of the pancreatic head, hepaticojejunostomy, and gastrojejunostomy. The patient did not develop postoperative complications, and he was discharged from the hospital on postoperative day 14. For 5 years after surgery, no abdominal pain or recurrent pancreatitis was observed. Conclusion Our triple drainage procedure seems effective and minimally invasive for patients complicated with bile duct stenosis, duodenal stenosis, and portal vein stenosis.

Although vascular invasion is an important factor in the progression and treatment of hepatocellular carcinoma (HCC), it remains difficult to determine, on the basis of preoperative imaging alone, whether vascular invasion, especially microvascular invasion, has occurred. The current retrospective study enrolled 292 patients who, between 2004 and 2014, underwent curative hepatectomy as an initial treatment for HCC. The patients were divided between those with (n=70) and those without (n=222) microvascular invasion. Whether tumor-marker-based prediction of microvascular invasion was possible was assessed by comparing the preoperative serum α-fetoprotein (AFP) and prothrombin induced by vitamin K absence or antagonist-II concentrations between two groups of patients. The AFP concentration was significantly higher in patients with microvascular invasion compared with patients without microvascular invasion (P=0.0019). Stepwise logistic regression analysis demonstrated the AFP concentration and the logarithmic conversion ratio of the AFP gradient (log AFP grad) to be useful (P=0.0019; 0.0424) for predicting microvascular invasion. The serum AFP concentration and log AFP grad appear to be clinically useful in predicting microvascular invasion in patients with HCC.

Long-term repetitive movements, such as opening and closing scissors, increase strain on muscles and joints. Amplitude probability distribution function (APDF) analysis of surface electromyogram (sEMG) data was used to quantify the burden of muscle activity. We aimed to test the hypothesis that scissors with a power-support device assist repetitive thumb movements to reduce potential myoelectric activity. Twenty female university students who met the eligibility criteria performed a cutting experiment, with and without power-support device scissors. The primary outcome was a change in muscle load due to sEMG data that were analyzed using APDF, and the secondary outcomes investigated the occurrence of muscle fatigue and pain. The adductor pollicis muscle showed a significant decrease in muscle activity with power assistance. In addition, it was also found that fatigue and pain of the thumb and on the radial side of the forearm were significantly lower under the power-assisted conditions. The results of this study suggest that the assistive action of scissors with a power-support device compensate for muscle load on the thenar eminence. This may be used as a reference value to prevent the occurrence of hand disorders for hairdressers.

This article explores the vertical aspects of the Jesuit confraternity system in the thirty community towns under Span­ish rule (1609−1767) designated as “Missions” or “Reductions” in the Río de la Plata region of South America. The principal docu­ments analyzed are the cartas anuas, the annual reports of the Jesuits. The chronological analysis is carried out with a view to tracing the process of integrating the Guaraní Indians into the Spanish colonial regime by means of the religious congregation founded in each Mission town. As a supplementary issue, we deal with the significance of the Spanish word policía (civility) used as a criterion to ascertain the level of culture attained by the Amer­indians. Normally the Jesuits considered members of indigenous confraternities to be endowed with policía, so they used confrater­nities to transplant Christian civility among the Guaraní Indians in the Spanish overseas colony.

Cholangiocarcinoma represents the second most common primary liver tumor after hepatocellular carcinoma. Mahanine, a carbazole alkaloid derived from Murraya koenigii (Linn.) Spreng, has been used as folk medicine in Thailand, where the liver fluke-associated cholangiocarcinoma is common. The expression of microphthalmia-associated transcription factor (MITF) is maintained at immunohistochemically undetectable levels in hepatocytes and cholangiocytes. To explore the regulation of MITF expression in the liver, we immunohistochemically analyzed the MITF expression using hepatocellular carcinoma and cholangiocarcinoma specimens of the human liver cancer tissue array. MITF immunoreactivity was detected in subsets of hepatocellular carcinoma (6 out of 38 specimens; 16%) and cholangiocarcinoma (2/7 specimens; 29%). Moreover, immunoreactivity for glioma-associated oncogene 1 (GLI1), a transcription factor of the Hedgehog signaling pathway, was detected in 55% of hepatocellular carcinoma (21/38 specimens) and 86% of cholangiocarcinoma (6/7 specimens). Importantly, MITF was detectable only in the GLI1-positive hepatocellular carcinoma and cholangiocarcinoma, and MITF immunoreactivity is associated with poor prognosis in patients with hepatocellular carcinoma. Subsequently, the effect of mahanine was analyzed in HepG2 human hepatocellular carcinoma and HuCCT1 and KKU-100 human cholangiocarcinoma cells. Mahanine (25 µM) showed the potent cytotoxicity in these hepatic cancer cell lines, which was associated with increased expression levels of MITF, as judged by Western blot analysis. MITF is over-expressed in subsets of hepatocellular carcinoma and cholangiocarcinoma, and detectable MITF immunoreactivity is associated with poor prognosis in patients with hepatocellular carcinoma. MITF expression levels may be determined in hepatic cancer cells by the balance between the Hedgehog signaling and the cellular stress.

Regorafenib is an oral multikinase inhibitor affecting angiogenesis, oncogenesis, metastasis, and tumor immunity. As a systemic treatment, it has been shown to provide survival benefits in hepatocellular carcinoma (HCC) patients progressing on sorafenib treatment. We report herein a case of HCC with hepatic vein tumor thrombosis protruding into the inferior vena cava (IVC-HVTT) which was successfully treated by surgery following second-line chemotherapy with regorafenib. A 79-year-old man with chronic hepatitis was diagnosed with HCC. Computed tomography revealed a solitary tumor in segments 7 and 8 and an IVC-HVTT from the right hepatic vein. Since IVC-HVTT removal is a difficult procedure, the tumor was diagnosed as unresectable, and administration of sorafenib was started. Five weeks later, the lesion had increased in size by 15.3%; subsequently, regorafenib was given as second-line therapy for 12 months. After shrinkage of the IVC-HVTT, the patient was referred to our hospital for surgery. One month after the cessation of regorafenib, an extended resection of segment 8 and total removal of the IVC-HVTT was successfully performed without using total hepatic vascular exclusion. There were no serious postoperative complications. Additionally, there has been no recurrence for about 2 years since the initial therapy.

Long interspersed element-1 (LINE-1) is a mammalian transposable element, and its genomic insertion could cause neurological disorders in humans. Incidentally, LINE-1 is present in intron 3 of the microphthalmia-associated transcription factor (Mitf) gene of the black-eyed white mouse (Mitfmi-bw allele). Mice homozygous for the Mitfmi-bw allele show the white coat color with black eye and deafness. Here, we explored the functional consequences of the LINE-1 insertion in the Mitf gene using homozygous Mitfmi-bw mice on the C3H background (C3H-bw mice) or on the C57BL/6 background (bw mice). The open-field test showed that C3H-bw mice moved more irregularly in an unfamiliar environment during the 20-min period, compared to wild-type mice, suggesting the altered emotionality. Moreover, C3H-bw mice showed the lower serum creatinine levels, which may reflect the creatine deficiency. In fact, morphologically abnormal neurons and astrocytes were detected in the frontal cortex of bw mice. The immunohistochemical analysis of bw mouse tissues showed the lower intensity for expression of guanidinoacetate methyltransferase, a key enzyme in creatine synthesis, in neurons of the frontal cortex and in glomeruli and renal tubules. Thus, Mitf may ensure the elongation of axons and dendrites by maintaining creatine synthesis in the frontal cortex.

Melanocytes develop from the vertebrate embryo-specific neural crest, migrate, and localize in various organs, including not only the skin but also several extracutaneous locations such as the heart, inner ear and choroid. Little is known about the functions of extracutaneous melanocytes except for cochlear melanocytes, which are essential for hearing ability. In this study, we focused on the structure of the choroid, in which melanocytes are abundant around the well-developed blood vascular system. By comparing structural differences in the choroid of wild-type and melanocyte-deficient Mitfmi-bw/Mitfmi-bw mutant mice, our observations suggest that choroidal melanocytes contribute to the morphogenesis and/or maintenance of the normal vasculature structure of that tissue.

AIM To compare the cells of mucosal extension (ME) and radial invasion (RI) in hilar cholangiocarcinoma (HCCA) for optimal resection. MATERIALS AND METHODS Forty-six patients underwent surgery for HCCA between 1992 and 2004. Immunohistochemical expressions of p53, Ki-67, matrix metalloproteinase-7 (MMP7), mucin 1 (MUC1), and E-cadherin were assessed at five different sites of the tumour and compared between the recurrence and non-recurrence groups. RESULTS Expression of E-cadherin was significantly lower in RI cells than in ME cells, and that of MMP7 and MUC1 was significantly higher in RI cells than in ME cells. Ki-67 expression was higher in ME cells than in RI cells. During the 11-year follow-up, recurrence in patients with R0 resection was associated with significantly lower E-cadherin, higher MMP7, and higher Ki-67 expression. CONCLUSION Removal of as many RI cells as possible should be a priority in resection of HCCA, followed by removal of ME cells. E-Cadherin appears to be associated with recurrence of HCCA.

Es bien sabida la existencia de varias organizaciones sociopolíticas en las misiones jesuítico-guaraníes. Entre ellas se encontraba nel cabildo, la milicia, la congregación y el cacicazgo. Basándose en descripciones de cronistas jesuitas, los historiadores con frecuencia sostienen que la mayoría de los cargos de estas organizaciones eran ocupados por caciques con el título de Don. Sin embargo, el análisis comparativo de los padrones de indios guaraníes y los reclutamientos de soldados demuestra que en la segunda mitad del XVII se introdujo en las misiones jesuíticas una organización militar cuyo principio era fundamentalmente diferente al del cacicazgo, mientras que la mayor cantidad de los cargos militares eran ocupados por indios que no habían sido caciques. El propósito de este artículo es analizar algunos documentos que contienen listas de nombres de indios guaraníes para establecer cuál fue el rol de los caciques en el cacicazgo y en la milicia,y el cambio que experimentó su poder dentro de estas dos organizaciones que estructuraban las misiones jesuíticas del Río de la Plata.

Background The inflammation-based Glasgow prognostic score (GPS) has been demonstrated to be prognostic for various tumors. We investigated the value of the modified GPS (mGPS) for the prognosis of patients undergoing curative resection for colorectal liver metastases (CRLM). Methods A total of 343 patients were enrolled onto this study. The mGPS was calculated as follows: mGPS-0, C-reactive protein (CRP) ≤10 mg/L; mGPS-1, CRP >10 mg/L and albumin ≥35 g/L; and mGPS-2, CRP >10 mg/L and albumin

A 61-year-old female underwent right hemihepatectomy and caudate lobectomy for hilar cholangiocarcinoma in 1999. Ten years later, increasing serum carbohydrate 19-9 was detected by routine follow-up. Subsequent positron emission tomography revealed an asymptomatic lesion in the right 11th rib. As the mass steadily grew in size, the lesion was resected en bloc with the affected rib and muscle. The histopathological findings closely resembled those of the primary cholangiocarcinoma. Thus, the tumor was diagnosed as a metastatic recurrence 10 years after resection of the primary tumor. There have been a few reports of cholangiocarcinoma recurrence in long-term survivors at the surgical margins, peritoneum, or transhepatic drainage route. However, there are no reports of solitary extra-abdominal recurrence. This case highlights the need for careful follow-up of patients with cholangiocarcinoma and nodal metastasis, even in the absence of recurrence for >5 years after curative resection.

Background In the present study, we conducted a multicenter nationwide survey to investigate the effects of preoperative fluorine-18-fluorodeoxyglucose (FDG) positron emission tomography (PET) on the prediction of hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT). Methods From 16 Japanese LT centers, data were collected on 182 recipients with HCC who underwent living donor liver transplantation (LDLT) between February 2005 and November 2013. PET-positive status was defined as increased uptake of FDG in the tumor compared to the surrounding non-tumor liver tissue. The median follow-up after LDLT was 54.5 months (range 1–125 months). Results Postoperative HCC recurrence occurred in 23 patients. Multivariate analysis revealed that exceeding the Milan criteria (MC), alpha-fetoprotein (AFP) level ≥115 ng/ml, and PET-positive status were significant and independent risk factors for recurrence. In the over-MC group, a subgroup of patients with AFP level

Microphthalmia-associated transcription factor (Mitf) is a key regulator for differentiation of melanoblasts, precursors to melanocytes. The mouse homozygous for the black-eyed white (Mitfmi-bw) allele is characterized by the white-coat color and deafness with black eyes due to the lack of melanocytes. The Mitfmi-bw allele carries LINE-1, a retrotransposable element, which results in the Mitf deficiency. Here, we have established the black spotting mouse that was spontaneously arisen from the homozygous Mitfmi-bw mouse lacking melanocytes. The black spotting mouse shows multiple black patches on the white coat, with age-related graying. Importantly, each black patch also contains hair follicles lacking melanocytes, whereas the white-coat area completely lacks melanocytes. RT-PCR analyses of the pigmented patches confirmed that the LINE-1 insertion is retained in the Mitf gene of the black spotting mouse, thereby excluding the possibility of the somatic reversion of the Mitfmi-bw allele. The immunohistochemical analysis revealed that the staining intensity for beta-catenin was noticeably lower in hair follicles lacking melanocytes of the homozygous Mitfmi-bw mouse and the black spotting mouse, compared to the control mouse. In contrast, the staining intensity for beta-catenin and cyclin D1 was higher in keratinocytes of the black spotting mouse, compared to keratinocytes of the control mouse and the Mitfmi-bw mouse. Moreover, the keratinocyte layer appears thicker in the Mitfmi-bw mouse, with the overexpression of Ki-67, a marker for cell proliferation. We also show that the presumptive black spots are formed by embryonic day 15.5. Thus, the black spotting mouse provides the unique model to explore the molecular basis for the survival and death of developing melanoblasts and melanocyte stem cells in the epidermis. These results indicate that follicular melanocytes are responsible for maintaining the epidermal homeostasis; namely, the present study has provided evidence for the link between melanocyte development and the epidermal microenvironment.

Microphthalmia-associated transcription factor (Mitf) is a regulator for differentiation of melanoblasts that are derived from the neural crest. The mouse homozygous for the black-eyed white (Mitfmi-bw) allele is characterized by the white coat color and deafness, with black eye that is associated with the lack of melanocytes in skin and inner ear. The Mitfmi-bw mutation is an insertion of the LINE1 retrotransposable element into intron 3 of the Mitf gene that causes the selective deficiency of the melanocyte-specific Mitf isoform, Mitf-M. Here, we show the expression of Mitf-M mRNA in the trunk region of the homozygous Mitfmi-bw (bw) mouse at embryonic days (E) 11.5 and E12.5, but Mitf-M mRNA is undetectable at E13.5. In addition, using bw mouse that carries the lacZ transgene under the control of a melanoblast-specific promoter, we show that the number of migrating melanoblasts in bw embryos was less than 10% of that in control embryos at E11.5 and E12.5, and melanoblasts disappear by E13.5. The loss of melanoblasts in bw embryos was probably caused by apoptosis. Finally, forced expression of Mitf-M in the cultured neural tube of bw embryos ensured the differentiation of melanoblasts. Therefore, the correct dose of Mitf-M is required for the normal development of melanoblasts.

The number of elderly patients who undergo hepatectomy for hepatocellular carcinoma (HCC) has been increasing. Therefore, criteria for selection of an appropriate hepatectomy procedure are required.Two hundred and twenty-nine HCC patients undergoing hepatectomy were enrolled in the present study. Patients were classified into two groups: the elderly group (age ≥75 years, n=34) and the non-elderly group (age75 years, n=195). The hepatectomy procedure was selected based on the prognostic score (PS) formula, that includes patient age as a variable.The incidence of non-anatomical resection was higher (p=0.015) and the weight of resected specimens was lower (p=0.019) in the elderly group than in the non-elderly group. No significant difference was observed in the postoperative complication rate between the two groups. The 5-year survival rates were comparable between the two groups.Favorable short- and long-term outcomes can be obtained based on cautious selection criteria for hepatectomy procedures, while considering patient age, in the treatment of elderly patients with HCC.

En-bloc liver resection with caudate lobectomy (segmentectomy 1) is the standard procedure for hilar cholangiocarcinoma. Although its surgical mortality has been reduced below 5%, it is still a potentially hazardous operation. Complete tumor resection with negative surgical margins and safe reconstruction of bilio-enteric continuity are two principles of the surgical treatment of hilar cholangiocarcinoma. Surgeons must pay attention to the variation of the hilar structures including portal veins, hepatic arteries, and bile ducts. Three-dimensional imaging is beneficial not only for understanding anatomical variations but also for preoperative simulations. Since the U-point can be identified by both preoperative imaging and intraoperative inspection, it can be used as the landmark for the hepatectomy and the dissection point of the hilar plate. The hanging maneuver might be useful for both hepatic parenchymal dissection and bile duct dissection just right of the U-point. For safe biliary reconstruction, stay sutures in the anterior wall and transanastomotic stents may be helpful.

Purpose We studied the risk factors for postoperative mortality between patients who underwent emergency or elective living-donor liver transplantation (LDLT). Methods Forty-seven patients underwent LDLT in our institute, 16 for emergencies and 31 as elective procedures. The emergency LDLT status was applied to cases in which the time period between referral to our institution and transplantation did not exceed 10 days, and in which liver failure was accompanied by the presence of any degree of hepatic encephalopathy. Results With regard to preoperative factors, age (P = 0.03), the model for end-stage liver disease score (P = 0.001), preoperative tracheal intubation (P = 0.001), ratio between arterial oxygen tension and fractional inspired oxygen (PaO2/FiO2 ratio) (P = 0.03), steroid therapy use (P = 0.001), lymphocyte count (P = 0.02), and cases requiring hemodiafiltration (P = 0.001) differed significantly between the two groups. Postoperative pneumonia occurred more frequently in emergency LDLT patients than in elective LDLT patients (P = 0.006). Invasive pulmonary aspergillosis (IPA) was the main cause of postoperative death in emergency LDLT patients, and, in a univariate analysis, a preoperative status of high serum (1 → 3)-β-d-glucan (>20 pg/ml, P = 0.001), advanced age (>52 years, P = 0.02), and a low PaO2/FiO2 ratio (

BACKGROUND: Although tumor reduction via present-day prehepatectomy chemotherapy can render initially unresectable disease potentially resectable, little is known about the effects of such chemotherapy on liver metastases with known attachment to or invasion of major intrahepatic vessels. We histologically assessed the relationships of liver tumors to major intrahepatic vessels after chemotherapy. METHODS: In 45 patients who underwent chemotherapy and hepatectomy with pretreatment images showing metastases attached to or invading major intrahepatic vessels, 77 metastases showed attachment to or invasion of 96 vessels. RESULTS: Using postchemotherapy imaging, 11 of 77 metastases (14.3%) appeared separated from 12 of 96 major hepatic vessels (12.5%). Among 83 vessels later examined pathologically, 29 showed direct invasion (35%) and 10 showed attachment (12%). Tumors involved another 9 vessels (11%) that were separated surgically from the tumor and preserved during hepatectomy. Tumor attachment that exceeded 25% of vessel circumferences via imaging after chemotherapy was a factor associated with pathological vascular invasion or attachment according to multivariate analysis (relative risk, 8.449; 95% confidence interval, 1.961-36.415; P = .0042). CONCLUSIONS: Liver metastasis attachment to or invasion of major intrahepatic vessels is difficult to eradicate even with otherwise effective chemotherapy. Cancer 2012;. © 2011 American Cancer Society.

症例は46歳男性で，アルコール性慢性膵炎で通院中に膵尾部の仮性嚢胞と，嚢胞内に仮性動脈瘤を認めた．血管造影では仮性動脈瘤内に噴出する動脈波を認めコイリングを行ったが，膵炎の増悪を認めたため膵体尾部切除を施行した．術後徐々に主膵管が拡張し，膵炎症状の再燃がみられたため超音波内視鏡下に尾側拡張膵管のドレナージを試みたが不良であり，食事のたびに膵炎様症状を繰り返したため残膵の尾側拡張膵管と空腸の側々吻合術（Partington手術）を施行した．術後経過は良好で第10病日に軽快退院した．術後約1年5ヶ月経過しているが膵炎症状の再燃を認めず経過は良好である．本症例のように慢性膵炎で膵体尾部切除後の膵炎再燃に対してPartington手術を施行した報告はないが，積極的なドレナージ手術によりQOLの改善が得られると考えられた．

症例は63歳，女性．検診でHBsAg陽性を指摘され，経過観察中の腹部エコーで嚢胞性肝腫瘍を認めた．腹部CT，MRIでは肝内側区域に最大径5cmで内部に隔壁を伴った嚢胞性病変を認めた．腫瘍マーカーはいずれも正常範囲内であった．肝嚢胞腺癌と診断し，鑑別診断として中心壊死を伴った肝細胞癌，肝嚢胞内出血等を考えたが，腫瘍細胞播種の回避のため穿刺細胞診は施行せず，肝左葉切除術を実施した．摘出標本では腫瘍は平滑な被膜を有し，内腔は褐色粘液で充満され，被膜の一部に白色結節を認めた．病理組織学的には嚢胞壁は一層の円柱上皮からなり散在性に乳頭状増殖と軽度の細胞異型を認めた，白色結節は線維組織から成っていた．上皮直下の間質結合織は卵巣間質に類似しており，免疫染色でER，PGRともに陽性であったため卵巣様間質を伴った肝内胆管嚢胞腺腫と診断した．本疾患は術前確定診断が困難で癌を伴うこともあり，積極的な切除が必要であると考えられた．

Although heme oxygenase-1 (HO-1) is induced in keratinocytes after UV radiation, HO-1 expression during normal epidermal differentiation has not yet been reported. We showed by real-time PCR, western blotting, and ELISA that HO-1 mRNA and protein expression by cultured normal human keratinocytes was upregulated during epidermal differentiation induced by a high-calcium medium. Immunohistochemical staining and in situ hybridization showed the graduated expression of HO-1 in the upper epidermis, which was accompanied by suprabasal HO-1 mRNA expression, and the accumulation of bilirubin (BR) in the stratum corneum. We examined the activation of nuclear factor E2-related factor 2 (Nrf2), which is a pivotal transcription factor for HO-1 expression, by western blotting and by examining the mRNA expression of Nrf2 target genes, and excluded its role in HO-1 expression in epidermal differentiation. Next, we examined the regulation of HO-1 expression by inflammatory cytokines. IL-4 and IL-22 significantly reduced HO-1 mRNA and protein expression, whereas IL-1beta, IL-17A, and tumor necrosis factor-alpha (TNF-alpha) increased it. Finally, immunohistochemical studies on psoriatic lesional skin showed that HO-1 expression was downregulated in the parakeratotic epidermis, whereas it was retained in the orthokeratotic epidermis. These studies demonstrate that HO-1 is functionally expressed by keratinocytes in parallel with epidermal differentiation and that its expression is independently affected by several cytokines.