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The prognosis of patients with intrahepatic cholangiocarcinoma (ICC) is still poor, and the 5-year survival rate in patients undergoing radical surgery (R0) is less than one-third. Since the prognosis depends mainly on tumor factors, so early diagnosis is necessary. To extend the survival time of these patients with a poor prognosis, cases of long-term survival were examined based on the results of our experiences and the literature. It was found that the hepatitis virus was highly involved in the carcinogenesis of ICC, and patients who were infected with hepatitis virus had rather good survival. J. Med. Invest. 68 : 15-21, February, 2021.

Background : The aim of this study was to investigate quality of life (QOL) and night-time sleep disturbance in colon cancer patients with middle risk chemotherapy for proper antiemetic therapy. Methods : The study enrolled 139 patients with colorectal cancer. All patients received oxaliplatin or irinotecan-based chemotherapy. Patients completed a questionnaire about chemotherapy-induced nausea and vomiting and sleep disturbance. Sleep disturbance was checked, and the relationship between sleep disturbance and nausea was analyzed. Results : The prevalence of nausea was 48.9% (68 / 139). The degree of the nausea was slight / moderate / severe in 51 / 11 / 6 patients, and 12 patients had vomiting. Appetite showed no change / slightly decreased / half / one-fourth / none in 51 / 34 / 33 / 6 / 7 patients. There were significant differences in the mental component summary (MCS) score and the role-social component score (RCS). (MCS : nausea(+) vs nausea(-) 46.4 ± 1.1 vs 54.1 ± 1.1 p 0.01 RCS : nausea(+) vs nausea(-) 33.1 ± 2.1 vs 41.6 ± 2.1 p 0.01). Using the MCS with a cut-off score of 50, patients were divided into two groups, and nausea was significantly correlated with a low MCS score. Furthermore, patients were divided into two groups using a Pittsburgh Sleep Quality Index cut-off score of 6, and sleep disturbance was correlated with old age and second-line chemotherapy. Conclusions : Nausea affects QOL and night-time sleep of colon cancer patients with middle risk chemotherapy. J. Med. Invest. 67 : 338-342, August, 2020.

Purpose Carotid artery stenting (CAS) is a valuable alternative to carotid endarterectomy, especially in high-risk patients. However, the reported incidences of perioperative stroke and death remain higher than for carotid endarterectomy, even when using embolic protection devices (EPDs) during CAS. Our purpose was to evaluate 30-day major adverse events after CAS when selecting the most appropriate EPD. Methods We reviewed the clinical outcomes of 61 patients with 64 lesions who underwent CAS with EPDs. Patients who underwent CAS associated with thrombectomy and who had a preoperative modified Rankin scale score >3 were excluded from the analysis. The EPD was selected based on symptoms, carotid wall magnetic resonance imaging and lesion length, and we analyzed combined 30-day complication rates (transient ischemic attack, minor stroke, major stroke or death). Results Forty-nine patients were men and 12 were women. The median age was 72 years (range: 59–89 years) and 44 lesions were asymptomatic. A filter-type EPD was selected in 23 procedures, distal-balloon protection in 14 procedures and proximal-occlusive protection in 27 procedures. Two patients (3.1%) experienced a transient ischemic attack and one patient (1.6%) had a minor stroke within 30 days of the procedure. No patients experienced procedure-related morbidities (modified Rankin score >2) or death. Conclusions The perioperative stoke rate was low when we selected a proximal-occlusive-type EPD in high-risk patients with vulnerable carotid artery disease. Our algorithm for EPD selection was an effective tool in the perioperative management of carotid artery stenosis.

We clarified the safety and efficacy of preoperative chemoradiotherapy for locally advanced rectal cancer using a multidrug regimen (S-1 + oxaliplatin + bevacizumab). This multicenter phase II trial involved 47 patients with locally advanced rectal cancer. All patients received S-1 orally (80 mg/m2/day on days 1–5, 8–12, 15–19, and 22–26) and infusions of oxaliplatin (50 mg/m2 on days 1, 8, 15, and 22) and bevacizumab (5 mg/kg on days 1 and 15). The total radiation dose was 40 Gy delivered in daily fractions of 2 Gy via the four-field technique. The primary endpoint was the pathological complete response rate. The secondary endpoints were safety (incidence of adverse events) and clinical response, relapse-free survival, overall survival, local recurrence, R0 resection, downstaging, and treatment completion rates. All 47 patients received chemoradiotherapy, and 44 patients underwent curative resection. Two patients refused surgery and selected a watch-and-wait strategy. The pathological complete response rate was 18.2% in patients who underwent curative resection. The clinical response rate was 91.3% in 46 patients. Concerning hematotoxicity, there was one grade 4 adverse event (2.1%) and seven grade 3 events (14.9%). Diarrhea was the most frequent non-hematotoxic event, and the grade 3 event rate was 25.5%. Although preoperative chemoradiotherapy for patients with locally advanced rectal cancer using the S-1 + oxaliplatin + bevacizumab regimen did not achieve the expected pathological complete response rate, this regimen led to an improved clinical response rate.

Purpose: Endovascular therapy for emergent large vessel occlusion has been established as the standard approach for acute ischaemic stroke. However, the effectiveness and safety of endovascular therapy in the very elderly population has not been proved. Objective: To determine the safety and effectiveness of endovascular therapy in octogenarians and nonagenarians. Methods: We retrospectively reviewed all patients who underwent endovascular therapy at two stroke centres between April 2012 and July 2018. Functional outcome was assessed using the modified Rankin scale at 90 days after stroke or at discharge. A favourable outcome was defined as a modified Rankin scale score of 0–2 or not worsening of the modified Rankin scale score before stroke. Outcome was compared between younger patients (aged 46–79 years, n = 40) and octogenarians and nonagenarians (aged 80–97 years, n = 19). Results: Octogenarian and nonagenarian patients had pre-stroke functional deficit (modified Rankin scale score >1) more frequently than younger patients (57.9% vs. 20.0%, respectively, P = 0.0059). No difference was observed between very elderly and younger patients in the rate of successful reperfusion (89.5% vs. 67.5%, respectively, P = 0.11), favourable functional outcome (47.4% vs. 45.0%, respectively, P = 1.00) and mortality (21.1% vs. 27.5%, respectively, P = 1.00). On multiple regression analysis, successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were independent predictors of favourable outcome ( P = 0.0003, 0.015 and 0.028, respectively). Conclusions: Successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were clinical predictors of favourable outcome. However, we did not observe an age-dependent effect of clinical outcome after endovascular therapy.

BACKGROUND AND AIM Various randomized clinical studies have suggested that short- and long-term outcomes of laparoscopic surgery (LAP) for colorectal cancer are comparable with those of open surgery (OP). However, these studies were performed in high-volume hospitals. The aim of the present study was to compare the outcomes of LAP versus OP for colorectal cancer in rural hospitals. METHODS This was a multicenter retrospective propensity score-matched case-control study of patients who underwent colorectal surgery from January 2004 to April 2009 in 10 hospitals in Japan. All patients underwent curative surgery for pathologically diagnosed stage II or III colorectal cancer. The primary end point was 5-year overall survival (OS). The secondary end points were disease-free survival (DFS) and postoperative complications. RESULTS In total, 319 patients who underwent LAP and 1020 patients who underwent OP were balanced to 261 pairs. There was no significant difference in the OS and DFS between two groups. The operation time was significantly shorter for OP than for LAP. Blood loss was significantly lower in LAP than in OP. There was no difference in intraoperative morbidity between the two groups. The postoperative morbidity was significantly lower in LAP than in OP. The hospital stay was significantly shorter in LAP than in OP. There was no significant difference in 90-day postoperative mortality. CONCLUSIONS Laparoscopic surgery may be a feasible option for colorectal cancer in rural hospitals.

Patient: Male, 57-year-old Final Diagnosis: Leptomeningeal carcinomatosis Symptoms: Headache • visual acuity loss Medication: — Clinical Procedure: Venous sinus stenting Specialty: Oncology Objective: Unusual or unexpected effect of treatment Background: Cerebral venous sinus obstruction associated with leptomeningeal carcinomatosis is an extremely rare complication of advanced non-small-cell lung cancer. There is little information available on the efficacy of therapeutic options because of its rarity and extremely poor prognosis. Case Report: A 57-year-old man presented with severe headache, vomiting, and visual loss for 1 month. Head magnetic resonance venography (MRV) showed occlusion of the left transverse sinus. Gd-enhanced MRI showed no abnormal enhancement. Lumbar puncture intracranial pressure was higher than 40 cmH2O. Positive cerebrospinal fluid tumor cytology confirmed the diagnosis of leptomeningeal carcinomatosis (LC). The headache was relieved by repeated lumbar punctures, and ventriculo-peritoneal shunt was performed. Cerebral angiography showed severe stenosis of the left transverse sinus without thrombosis, and significant delay of cerebral circulation. The transverse sinus stenosis was judged to be contributing to raised intracranial pressure, and the patient underwent left transverse sinus stent placement. After the procedure, his visual acuity improved, the visual field was enlarged, and his headache could be controlled by medication. Follow-up Gd-enhanced MRI showed dural enhancement and spinal dissemination. Because molecular biology of the surgical specimen showed epidermal growth factor receptor (EGFR)-activating mutations, he was treated with osimertinib for 2 months. He survived for 8 months following the diagnosis of LC and left transverse sinus stenosis. Conclusions: Venous sinus stenting can offer an effective palliative interventional option for symptom relief of severe headache and visual symptoms, even in the end stage of malignancy.

Objective To determine the safety and effectiveness of emboli protection during carotid artery stenting (CAS). Methods The clinical outcomes of 59 patients who underwent CAS with emboli protection devices were reviewed. Patients who underwent CAS associated with thrombectomy and who had preoperative mRS >3 were excluded from the study. 46 patients were male, and 13 were female. The median age was 72.5 years (range 59–89), and 44 lesions were asymptomatic. Emboli protection device was selected based on the presence of symptom, carotid wall MRI, and lesion length. The combined 30 day complication rates (transient ischemic attack, minor stroke, major stroke, or death) were analyzed. Results Filter-type emboli protection device was selected in 23 procedures, distal balloon protection in 16 procedures, and proximal occlusive protection in 21 procedures. Our patients (6.8%) experienced a transient ischemic attack, and one patient (1.7%) had a minor stroke within 30 days of the procedure. No patients experienced procedure-related morbidities (mRS >2) or deaths. Conclusions Our data suggest that algorithmic selection of emboli protection based on the presence of symptom, carotid wall MRI, and lesion length can be effective in the prevention of major ischemic adverse events. Disclosures Y. Kawabata: None. N. Nakajima: None. H. Miyake: None. S. Fukuda: None. T. Tsukahara: None.

Phase-contrast magnetic resonance angiography (PC-MRA) is useful for the quantitative measurement of blood flow volume (BFV) in the internal cerebral arteries (ICAs) and basilar artery (BA). A 45-year-old man was diagnosed with a non-hemorrhagic high-flow arteriovenous malformation (AVM) in the right temporal lobe. PC-MRA examinations of the bilateral ICAs and BA were conducted before treatment, at five days and at one and three months after the operation. The patient underwent preceding endovascular embolization of the deep part of the nidus and feeders. There were numerous feeders from the superior MCA trunk, which directly passed through the nidus to the normal brain. Therefore, the nidus was completely removed while maintaining the flow of the main superior MCA trunk in a passing artery. The BFV of the right ICA before AVM treatment was extremely high (mean: 675.7, systolic: 896.1, diastolic: 518.5 mL/min). Five days after the nidus resection, the BFV of the right ICA was decreased by almost half of that before treatment, and it was decreased even more at one month after the operation. The BFVs of the left ICA and BA were slightly increased before the operation and returned to normal values after the operation. The diastolic total BFV was immediately decreased after the operation, but the systolic total BFV was not sufficiently decreased at five days after the operation. Therefore, the difference between these systolic and diastolic total BFVs was higher at five days after the operation than before the operation. The systolic and diastolic total BFVs were decreased to normal levels one month after the operation. PC-MRA is a convenient and useful tool for quantifying BFVs in AVMs and can help plan the treatments. More research is needed to establish a definite role for PC-MRA in the quantification of flow changes in the treatment of high-flow AVMs.

Background The recurrence rate of chronic subdural hematoma (CSDH) after trepanation is relatively high and involves various factors. We encountered an extremely rare case in which metastasis of an extracranial malignant tumor to the hematoma capsule was thought to be causing short-term repeated recurrences of CSDH. Case Description The patient was a 74-year-old man who had undergone bur hole evacuation of left CSDH 7 months earlier and had been receiving chemotherapy for stage IV gastric cancer for the preceding 6 months. He presented with symptoms of right hemiparesis and was diagnosed with left CSDH. Bur hole evacuation was performed twice, but the hematoma enlarged again both times within a short period. A third bur hole evacuation was performed after middle meningeal artery embolization, but the hematoma again enlarged shortly thereafter. Hematoma enlargement was finally suppressed by extracting the hematoma capsule under craniotomy. In histopathologic examinations, hematoxylin-eosin staining showed poorly differentiated adenocarcinoma primarily along the luminal side of the hematoma capsule and immunohistochemical staining showed results identical to findings from the existing gastric cancer. Pathologic results confirmed metastasis of the gastric cancer to the hematoma capsule, and this was considered to be the cause of short-term repeated recurrence of CSDH. Conclusions To the best of our knowledge, this is the first report of metastasis to a hematoma capsule originating from an extracranial malignant tumor. The clinical course in the present case suggests metastasis of extracranial malignant tumor to the CSDH capsule as an extremely rare cause of recurrence.

Purpose Simple rating scale for calcification in the cervical arteries and the aortic arch on multi-detector computed tomography angiography (MDCTA) was evaluated its reliability and validity. Additionally, we investigated where is the most representative location for evaluating the calcification risk of carotid bifurcation stenosis and atherosclerotic infarction in the overall cervical arteries covering from the aortic arch to the carotid bifurcation. Method The aortic arch and cervical arteries among 518 patients (292 men, 226 women) were evaluated the extent of calcification using a 4-point grading scale for MDCTA. Reliability, validity and the concomitant risk with vascular stenosis and atherosclerotic infarction were assessed. Results Calcification was most frequently observed in the aortic arch itself, the orifices from the aortic arch, and the carotid bifurcation. Compared with the bilateral carotid bifurcations, the aortic arch itself had a stronger inter-observer agreement for the calcification score (Fleiss’ kappa coefficients; 0.77), but weaker associations with stenosis and atherosclerotic infarction. Calcification at the orifices of the aortic arch branches had a stronger inter-observer agreement (0.74) and enough associations with carotid bifurcation stenosis and intracranial stenosis. In addition, the extensive calcification at the orifices from the aortic arch was significantly associated with atherosclerotic infarction, similar to the calcification at the bilateral carotid bifurcations. Conclusions The orifices of the aortic arch branches were the novel representative location of the aortic arch and overall cervical arteries for evaluating the calcification extent. Thus, calcification at the aortic arch should be evaluated with focus on the orifices of 3 main branches.

Summary Background & aims A late evening snack (LES) is recommended for improving starvation state in cirrhotic patients. The non-protein respiratory quotient (npRQ) is an important index for evaluating the indications and effectiveness of LES. Indirect calorimetry is used to determine npRQ, but it is expensive and not available in many hospitals. The aim was to find blood biochemical markers reflecting npRQ. Methods A total of 183 cirrhotic patients (M/F = 149/34) were enrolled. For each patient, fasting state npRQ was determined by indirect calorimetry. The relationships between npRQ and indices such as age, body mass index, platelet count, etiology, and levels of aspartate aminotransferase, alanine aminotransferase, total bilirubin, albumin, blood glucose, and non-esterified fatty acid (NEFA) were statistically analyzed. Results There was a significant negative correlation between the measured npRQ and serum NEFA levels, and the NEFA level was the strongest predictor of npRQ. Multiple regression analysis identified that the NEFA and Hepatitis B virus were predictors of npRQ. Conclusion These data suggest that fasting serum NEFA level is the most relevant biomarker to determine npRQ if indirect calorimetry is unavailable. Thus, serum NEFA levels may be useful to determine the indications and effectiveness of LES therapy in cirrhotic patients.

Introduction Histone deacetylase (HDAC) plays an important role in chromatin remodeling and gene expression, and in regulating cell cycle progression and differentiation. Furthermore, hypoxic conditions in the malignant tumor enhance HDAC function and increased HDAC activity is closely involved in worse malignant behavior through hypoxia inducible factor (HIF) activation. The aim of this study was to elucidate the correlation between HDAC expression and tumor malignant behavior including HIF-1α expression in intrahepatic cholangiocarcinoma (IHCC). Methods Thirty-five patients with IHCC who underwent hepatic resection were evaluated. HDAC1 and HIF-1α expressions were determined immunohistochemically, and the patients were divided into 2 groups: the HDAC1 positive group ( n = 21) and the HDAC1 negative group ( n = 14). Clinicopathologic variables including HIF-1α expression were compared between the 2 groups. Results HDAC1 expression correlated significantly with higher stage carcinoma, lymph node metastasis, and vascular invasion. The prognosis in the HDAC1 positive group was poorer than in the HDAC1 negative group (5-year survival: 78% vs 8%, P = .001). Furthermore, disease free survival rate in the HDAC1 positive group had significantly worse than that in the HDAC1 negative group ( P = .0003). In the multivariate analysis, HDAC1 positive expression was identified as the only independent prognostic factor for disease free survival (Hazard Ratio: 7.194, P = .0018). Furthermore, there was a significant correlation between HDAC1 expression and HIF-1α expression ( P = .007). Conclusion These findings suggested that HDAC1 positive expression was a potential new prognostic indicator of IHCC, and a possible promising molecular target through the regulation of HIF-1α.

Aim: The aim of this study was to investigate the characteristics of super-elderly hepatocellular carcinoma (HCC) patients aged 80 years or more who underwent hepatectomy and to clarify whether elderly patients with HCC benefit from hepatectomy. Methods: Between March 1992 and December 2008, 278 patients who underwent curative hepatectomy for HCC were investigated. Super-elderly patients were defined as those aged 80 years or more. Clinicopathological data and outcomes after hepatectomy were compared between super-elderly and non-super-elderly groups. Results: Preoperative parameters, such as biochemical examinations, and liver function tests in the non-super-elderly group were comparable with those of the super-elderly group (n = 11). Exceptionally, albumin level in the super-elderly group was lower than that in the non-super-elderly group (P = 0.03). Surgical data and the prevalence of postoperative complications did not differ significantly between the two groups. No mortality was observed in the super-elderly and non-super-elderly group. Conclusions: Hepatectomy for HCC was a feasible option even in super elderly patients aged 80 years or older with accurate selection.

To investigate the prognostic factors of peripheral-type intrahepatic cholangiocarcinoma (PP-IHCC) and evaluate the surgical outcomes according to surgical strategy alterations. Twenty-two patients were divided into two groups according to the surgical strategy: an extended surgery group (Ex group: n = 10), composed of those who underwent hepatic lobectomy combined with lymph node (LN) dissection and bile duct resection; and a customized surgery group (Cx group: n = 12), composed of those who underwent hepatectomy and bile duct resection according to tumor spread. LN dissection was not performed in patients without LN metastasis. Multivariate analysis revealed that R2 resection, LN metastasis, and intrahepatic metastasis were independent prognostic factors. LN dissection was significantly infrequent in the Cx group. Survival after curative resection was similar in the two groups (3-year survival: 42.9 vs. 57.1%). Liver metastasis was the most frequent primary recurrence, occurring in more than 80% of patients from both groups. Curative surgery might improve the prognosis of patients with PP-IHCC, but routine LN dissection is not recommended, particularly for patients without LN metastasis. Surgery alone, including LN dissection, cannot control this type of tumor, and additional treatment should be given.

We describe a new technique of ultrasound (US)-guided microwave coagulation (MC) of the Glissonean pedicle, performed before transection to control the inflow and select the resection area. This report introduces our procedure and evaluates the outcomes of patients treated using this technique.The Glissonean pedicles feeding the segment or cone unit were coagulated by US-guided MC, after which transection was performed. We used this US-guided MC technique to perform anatomical resections in 12 patients with hepatocellular carcinoma (MC group). We compared the outcomes of this group with those of a historical group of 10 patients who underwent conventional hepatectomy (control group). The two groups were well matched for age, tumor size, location, and type of hepatectomy.The mean operative times were similar, but the mean blood loss was significantly lower the in MC group than in the control group. Recurrence developed in four patients from the MC group, but local recurrence was not observed. Bile leakage occurred in one patient from the MC group, but the incidences of postoperative complications did not differ between the groups.Our procedure allows anatomical resection to be performed safely and easily, and helps prevent intrahepatic metastasis via portal flow during the transection.

The purpose of this study was to clarify the clinical predictors of delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (SAH).102 patients with ruptured cerebral aneurysms were treated (77 by clipping and 25 by coiling). 40 patients were male and 62 were female. Median age was 59 years (range 31-88). The modified Rankin Scale was used to assess functional outcomes 3 months after treatment or at discharge. The associations between potential clinical risk factors and DCI after SAH were assessed using the χ(2) test.52 patients (51.0%) had a good outcome and 13 patients (12.7%) died despite treatment. DCI was observed in 26 patients and hydrocephalus was observed in 37 patients. There were marginal differences in clinical outcomes between the treatment groups (p=0.053), mainly because functional outcomes were significantly superior in the coiling group (p=0.04) in patients with severe SAH. DCI was seen less frequently in the coiling group than in the clipping group (4.0% vs 32.4%, p=0.001). The presence of hydrocephalus was significantly associated with the occurrence of DCI (p0.001). Multivariate logistic regression analysis also showed that the treatment modality and the presence of hydrocephalus were independent risk factors for DCI.DCI was less frequently observed in the coiling group, and clinical outcomes were also superior in the coiling group, especially for patients with severe SAH. The results showed a significant correlation between DCI and hydrocephalus.

症例は65歳，女性．腹痛，食思不振，貧血を認め，当院紹介となった．腹部画像検査で，下腹部の巨大な腫瘤と肝内に1cm大の腫瘤を認めた．回腸腫瘍，肝転移疑いの術前診断のもと手術を行った．術中所見として多発肝転移を認め，回盲部切除術，肝転移生検，肝転移巣のラジオ波焼灼術を施行した．摘出された腫瘍は最大径16cmであり，組織学的には胞巣状，索状に増殖する未分化な腫瘍細胞を認め，免疫組織学的診断で内分泌細胞癌と判断した．また一部に高分化腺癌を認め，以上より腺内分泌細胞癌の診断に至った．小腸内分泌細胞癌の本邦報告例は自験例を含めて16例であり，経過から非常に予後不良な癌と示唆された．本疾患の有効な治療法は確立されておらず，今後の症例の集積が必要である．

Background This study aimed to investigate regulatory mechanisms of hepatocyte proliferation by comparing liver regeneration of the remnant lobe after 70% partial hepatectomy (PH) and portal vein branch ligation (PBL) in rat. Methods Expressions of activins βA, βC, and βE and their receptors were investigated after PH and PBL. The proliferating cell nuclear antigen (PCNA) labeling index was used to monitor hepatocyte proliferation. Results The PCNA labeling index in the regenerative lobe of PBL rats reached a peak at 48 h, a delay of 24 h compared with the remnant lobe in PH rats. In the postoperative early stage, the expression of activin βA, βC, and βE mRNAs was stronger in PBL than PH. At 72 h the expression of activin receptor type IIA mRNA reached a peak in PH but was significantly lower in PBL. Conclusions Hepatocyte proliferation, and the regulated expression of activins and their receptors, differs during liver regeneration after PH and PBL in the rat. Thus, regulation of activin signaling through receptors is one of the factors determining liver regeneration after PH and PBL.

A superoxide-producing enzyme, NADPH oxidase 1 (Nox1), dominantly expressed in the colon, is implicated in the pathogenesis of colon cancer. Immunohistochemistry showed that Nox1 was constitutively expressed in surface mucous cells. Adenomas and well differentiated adenocarcinomas up-regulated Nox1 expression. Ki-67-negative, well differentiated tumor cells contained abundant Nox1, whereas Ki-67-positive, proliferating cells did not express it. This differentiation-dependent expression in normal as well as tumor tissues suggests distinct roles of Nox1 besides mitogenic function. Nuclear factor (NF)-kappaB was predominantly activated in adenoma and adenocarcinoma cells expressing abundant Nox1, suggesting that Nox1 may stimulate NF-kappaB-dependent antiapoptotic pathways in colon tumors.

We report a patient with duodenal varices oozing blood who had undergone low anterior resection of the rectum and resection of the liver tumor because of multiple liver metastasis from rectal cancer 80 months previously. Although endoscopic variceal ligation (EVL) was carried out for the ruptured duodenal varices, their bleeding persisted and hepatic encephalopathy also appeared. Finally, balloon occluded retrograde transvenous obliteration (BRTO) with percutaneous transhepatic obliteration (PTO) was carried out for the duodenal varices. Percutaneous transhepatic portography revealed detailed hemodynamics. Following PTO, the duodenal varices were stagnated by BRTO, and no complications were recognized. No re-bleeding episode has been observed since the treatment. In addition, the hepatic encephalopathy was also improved.

Background : The prognosis of liver transplantation for liver cancer is determined by recurrence in the liver graft. In this study, the effects of immunosuppressors, FK506 and cyclosporine A (CsA) on the migration of liver cancer cells were investigated. Methods : The effects of FK506 at concentrations of 1-100 ng/mL and CsA at 1-1000ng/mL on the growth of poorly and well differentiated human hepatocellular carcinoma cell lines, HLE and HuH-7, respectively, were examined. After treatment of these cells with FK506 and CsA, the growth of these cells, their cytotoxicities and invasion assay on the Matrigel basement membrane invasion chamber were evaluated. In addition, the effects of FK506 and CsA on the changes in the production of a soluble intercellular adhesion molecule-1 (sICAM-1) of these cells were measured. Results : FK506 and CsA at concentrations of 1-10 ng/mL inhibited the growth of both HLE and HuH-7 and those immunosuppressors at concentrations over 100 ng/mL exhibited cytotoxicity on these cells. FK506 at concentration of 1ng/mL significantly inhibited the invasion of poorly differentiated HLE, but not well differentiated HuH-7, after treatment for 2-5 days in culture (p

To investigate the lymph network change in pancreatic duct obstruction in pigs as a model of pancreatic cancer invading pancreatic duct, six domestic pigs weighing 17-40 kg underwent surgery as protocol. Two of them were controls, and the others underwent ligation of the pancreatic duct as a model of ductal obstruction. A CH 40 and lipiodol mixture was injected in their pancreas at 7 or 21 Days after first operation. Radiographic examination had been also performed. Five or 14 days later, they were examined radiographically, and sacrificed for histological examination. Ligation of the pancreatic duct caused experimental pancreatitis. Dilatation of the pancreatic duct and dilatation of the lymph canal in the interlobular space of pancreas was demonstrated in the ligation group. CH 40 and lipiodol showed discrepancies in the distribution. There were not distinct differences between the two groups in a route of CH 40 traveling. Only fluoroscopic examination revealed an image of lipiodol enlargement to the caudal site in the ligated group. The congestive lymph system may have impaired flow like reflux.

Overproduction of heat shock protein 70 (HSP70) in the liver protects hepatocytes under various pathologic conditions. In this study we examined the effects of a nontoxic HSP70 inducer, geranylgeranylacetone (GGA), on acute hepatic failure after 95% hepatectomy in rats. When GGA (100 mg/kg) or vehicle was intragastrically administered to rats 4 hours before 95% hepatectomy, all 25 rats pretreated with vehicle died within 60 hours after the operation, whereas 10 of 25 rats pretreated with GGA survived. During the 24-hour postoperative period, GGA significantly suppressed the release of aspartate or alanine aminotransferase and elevation of the serum interleukin-6 level, and completely inhibited an increase in the serum level of tumor necrosis factor-alpha. Histologic examinations showed that GGA prevented hemorrhagic necrosis, which was observed in vehicle-treated livers more than 12 hours after the operation. During the 24-hour postoperative period, HSP70 induction was absent in remnant livers of vehicle-treated rats. In contrast, GGA stimulated the HSP70 mRNA expression and HSP70 accumulation within 4 hours, and viable hepatocytes contained abundant HSP70 in their nuclei. Our results suggest that GGA may prevent acute liver failure after massive hepatectomy, at least in part, by enhancing HSP70 induction in the remnant liver.

Several risk factors for arterial calcification have been reported but controversial. The aim of this study was to clarify the interactions among chronic kidney disease (CKD), diabetes mellitus (DM), hypertension, and dyslipidemia in altering the risk of arterial calcification in the three different arterial locations and the intramural location at the internal carotid artery (ICA) origins. Calcified burdens at the ICA origins, the aortic arch, and its orifices were evaluated in a retrospective fashion by using computed tomography angiography in 397 patients. The multivariate analyses were adjusted for age, gender, CKD, DM, hypertension, dyslipidemia, and current smoking status. Additionally, subgroup analyses in each variable were conducted. Our multivariate logistic regression analyses revealed that CKD was significantly associated with the outside-wall calcification at the ICA origins, whereas DM was only associated with the inside-ICA-wall calcification. Additionally, we found that DM increased the association between CKD and arterial calcification at the aortic arch and its orifices, and the outside-wall at the ICA origins. Hypertension was significantly associated with the calcification at the orifices of the aortic arch branches synergistically with CKD. Dyslipidemia did not have any significant association with calcification in any of the three vascular beds. CKD had the highest prevalence risk of calcification in common with the three different vascular beds. CKD in combination with DM, as well as hypertension in combination with CKD, were key relationships affecting the risk of arterial calcification, especially at the aortic arch and its orifices.

Biliary adenofibroma (BAF) is a rare, benign liver tumor. Herein, we report a case of BAF with histological features of imminent malignant changes. Ultrasound and CT revealed a solid 2.5-cm mass in the right liver lobe. The patient was asymptomatic and had no past medical history including liver disease. A general examination that included the abdomen and the laboratory data were normal. Because of the increase of its size, this tumor was surgically resected. Grossly, a 3.5-cm nodular mass abutted on the hepatic capsule was found, and its cut surface showed a well-circumscribed, whitish, and firm lesion that showed microcystic changes in the periphery and solid changes in the central parts. Histologically, the tumor showed a proliferation of tubulocystic structures embedded in a fibrous stroma. Microcysts were prevalent in the periphery, while tubular components with abundant fibrous stroma were in the central parts. The tubules were variably dilated and branched. This case closely resembled the previously reported cases of BAF, except that there were complicated papillary projections with fine fibrovascular cores in some of the microcysts and that the epithelial component in papillary projections showed dysplastic changes and increased cellular proliferative activities, implicating ominous features of imminent malignant changes. These dysplastic and papillary changes may be an intermediate lesion leading to malignancy, which have occasionally been reported in BAF.

症例は74歳の男性.主訴は心窩部痛.超音波検査で胆嚢底部の隆起性病変と胆石を認めた.腹腔鏡下胆嚢摘出術を予定し手術を施行したが,腹腔鏡所見で胆嚢癌が疑われたため胆摘は行わず,二期的手術の方針とした.腹部CT, MRIで胆嚢壁の肥厚と内腔に突出する隆起性病変を認め,結節浸潤型胆嚢癌の診断で胆嚢摘出術, S4a, S5区域切除術,肝外胆管切除術,リンパ節郭清(D2)を施行した.摘出標本では底部の胆嚢壁は肥厚し,結石が強固に胆嚢壁に固着していた.病理組織学的所見では黄色肉芽腫性胆嚢炎(XGC)を認め,結石と胆嚢壁は潰瘍の壊死組織や肉芽組織を介して連続していた.当科で経験したXGC 3例を含めた検討では,全例が術前に胆嚢癌と診断され,拡大手術が施行されていた.本症は画像上胆嚢癌との鑑別が困難であり,両者の合併例の報告もあることから,胆嚢癌を疑った場合には本症を念頭に置いて,慎重に術式を選択する必要があると考えられた.

症例は75歳女性.バリウム注腸造影で直腸RsSに全周性の大腸癌を認めた.注腸検査4日後に突然の腹痛が生じ腹部CT検査でバリウム腹膜炎と診断した.腹膜内洗浄ドレナージ術と人工肛門造設術を施行し,術後39病日に高位前方切除術を施行した.経過観察造影CTで肝S6の腫瘍性病変を認めCT-APとCT-Aで増大傾向を認めたため大腸癌肝転移と診断し肝切除術を施行した. S6の腫瘍性病変は病理学的検索で異物性の炎症性肉芽腫と診断され,バリウムの肝内への侵入による炎症性肝肉芽腫と類推された.バリウム性腹膜炎後の肝の腫瘍性病変に対してはバリウム性肉芽腫をも念頭に置き慎重な対応が必要と考えられた.

We report new surgical techniques for intraopera-tive microwave coagulation therapy (IMCT), conducted in three patients with large liver neoplasms with poor liver function or difficult tumor location. Anterolateral thoracotomy was performed for tumors in the right lobe to obtain a good operative field. Four electrode needles were inserted for microwave irradiation, with settings of 60 W, 45 s for coagulation and 1 s for dissociation. Clamping of the hepatoduodenal ligament was performed during IMCT. We began the coagulation at the bottom of the tumor, irradiating the tumor and the surrounding parenchyma to create regional necrosis with a safe margin. With these methods, we treated two women diagnosed with large hepatocellular carcinoma with liver cirrhosis and a man with liver metastasis from rectal cancer. The postoperative course of these patients was uneventful. A marked low-density area was seen in the region of therapy and no enhanced findings were observed on enhanced computed tomography postoperatively. However, in one patient, transcatheter embolization (TAE) was performed 1 month postoperatively because recurrence was noted on the bottom of the tumor. Thus, IMCT destroys the peripheral part of the tumor that may remain viable after TAE, but combination therapy with TAE is preferable, especially when a viable part exists within tumors. IMCT is an active, safe, and nontoxic therapeutic modality for large hepatic tumors, and is particularly applicable in patients with large hepatocellular carcinomas and poor liver function.

Background. Studies of human tumors and human tumor cell lines indicate that telomerase activity may play a critical role in the tumor cell growth by sustaining cellular immortality. Telomerase activity has been detected in different percentages in various carcinomas, but the incidence of positive telomerase activity in bile duct carcinomas and surrounding normal bile duct tissues in its relation with malignancy grades of tumors, depth of invasion, lymphatic and vascular invasion, and lymph node metastases has not been studied.

The daily pattern of energy expenditure and the oxidation rates of carbohydrates, fats, and protein were evaluated by indirect calorimetry in 18 control subjects (Group 1) and 34 cirrhotic patients who were divided into Groups 2a and 2b showing indocyanin green retention rates at 15 min of

It has been proved that antibiotics binding to penicillin-binding protein 3 (PBP3) are associated with the greater release of endotoxin than those that bind to PBP2 in both in vitro and animal models. The aim of this study is to evaluate the potential clinical implications of antibiotic-induced endotoxin release after hepatic resection. Forty-five patients who underwent hepatic resection in our clinic were enrolled. The patients were divided into two groups. Group A (n = 26): antibiotics that bind primarily to PBP3, including cefmetazole (CMZ), latamoxef (LMOX), flomoxef (FMOX), were used. Group B (n = 19); antibiotics that bind to both PBP2 and PBP3, including cefazolin (CEZ), cefoperazone (CPZ), cefotiam (CTM). Postoperative complications, liver functional tests, and chemical mediators [endotoxin, interleukins (IL-6, IL-8), tumor necrosis factor alpha (TNFalpha), granulocyte colony-stimulating factor (G-CSF), hepatotrophic growth factor (HGF) were examined after hepatic resection. There were no significant differences in the backgrounds of the two groups. Eight patients in each group developed postoperative complications; in particular, 9 of 13 patients with biliary tract carcinoma developed postoperative complications. No significant elevation of peripheral blood endotoxin was noted by the endospecy method, in any of the patients, although six died following sepsis. Pre- and postoperative levels of cytokines showed no significant difference between the two groups. Our data suggest that clinical antibiotic-induced endotoxin release would not occur after hepatic resection regardless of the antibiotic, probably owing to continuous scavenging of endotoxin from peripheral blood.

Objective In some patients with moyamoya disease, the development of spontaneous leptomeningeal collateral channels between the anterior cerebral artery (ACA) and other major arteries is poor. These patients require revascularization not only to the territory of the middle cerebral artery (MCA) but also to that of the ACA. For reliable revascularization to the ACA territory, we performed superficial temporal artery (STA)-ACA direct anastomosis in 5 of 58 patients with moyamoya disease who underwent cerebral revascularization at our institute during the last 8 years. Methods Because two patients presented with ischemic symptoms corresponding to the ACA territory after the ipsilateral STA-MCA anastomosis, we subsequently performed STA-ACA anastomosis. In three patients in whom hypoperfusion in the ACA territory was suspected based on preoperative angiograms and/or stimulated cerebral blood flow studies, we performed STA-ACA and STA-MCA anastomoses during a single operative procedure. After paramedian frontal craniotomy (diameter, approximately 5 cm), STA-ACA anastomosis was performed at the convexity, using a cortical branch of the ACA as a recipient. An interposed STA graft was used in four patients; all of the grafts were shorter than 4 cm. Results Bypass flow was satisfactory in four patients. One patient who underwent simultaneous STA-ACA and STA-MCA anastomoses had poor bypass flow, probably caused by spontaneous leptomeningeal collateral channels between the ACA and MCA. No patient had an ischemic attack after surgery. Conclusion Our method using a cortical branch of the ACA as a recipient and a branch of the STA for the interposed graft can be performed at the convexity and much more easily than in a deep operative field. Our experience with STA-ACA anastomosis indicates that this procedure is effective for revascularization of the ACA territory in patients with moyamoya disease.

肝細胞癌手術症例の初回術式について関連肝炎別に検討した.対象は遺残例を除くHBs抗原陽性例 (B群) 24例, HCV抗体陽性例 (C群) 67例で, B群で若年者に多く腫瘍径が大きかった.門脈侵襲, 肝内転移など予後に与える因子の陽性率は腫瘍径5cm以上の群で有意に高かったので, B群18例, C群63例の腫瘍径5cm未満症例について検討した.再発例はB群が4例 (22.2%), C群が36例 (57.1%) で, 再発様式はB群は2例 (50.0%) が残肝多発再発であったが, C群では多発再発は5例 (13.9%) のみで, 同側葉, 対側葉の別で差は見られなかった.[結論] 1.B群では肝機能が良好で再発様式も遺残再発が多く, 初回手術時に病巣をできるだけ大きく系統的に治癒切除すべきである, 2.C群では初回, 再発ともに多中心性発生と考えられる症例が多く局所のコントロールを目的とした支配グリソンを処理した部分切除で良いと考えられた.

33歳の女性の肝S3からS8におよぶ多発性転移 (H3) を有する直腸癌 (Rs, Ra) 症例に対し, 1期的にS3合併切除兼拡大肝右葉切除 (切除肝重量2,403g, 予想残存肝体積337ml) と低位前方切除術D2を施行. 術後, 肝不全や縫合不全を併発することなく軽快退院し, 術後2年6カ月を経過した現在, 肺転移を認めるが, 残肝再発を認めていない症例を経験した. H3を有する大腸癌症例であっても詳細な術前評価による理論的背景に基づいた肝, 大腸同時切除, 再建術は安全に施行でき, また, 1期的手術は2期的手術に比べ, 患者の負担が軽く, 担癌状態の期間を短縮させることができることから有用な手術手技であると考えられた.

A space-occupying lesion in the right hepatic lobe, with dilated peripheral bile ducts, was observed by ultrasonography and computed tomography in a 50-year-old man with right upper quadrant abdominal pain. One month later, this lesion evidenced rapid growth and a tumor thrombus, which completely occluded the main trunk and the left primary branch of the portal vein, had developed. The tumor was diagnosed as a cholangiocellular carcinoma with an unusual pattern of intravascular extension. The primary tumor and the portal tumor thrombus were resected via a right hepatic trisegmentectomy combined with resection of the portal vein and extrahepatic bile duct, using a superior mesenteric vein—left femoral vein catheter bypass (SMV—FV bypass). The SMV—FV bypass was found to effectively reduce intraoperative hemorrhage.

We studied whether the maximal excretion rate of indocyanine green (ICG Bmax) and the 2-h ICG excretion rate in the bile could be used to estimate the separate functions of the left and right liver in 20 patients with biliary obstruction at the hepatic hilus. ICG Bmax was measured after biliary decompression. An operative procedure that preserved the side of the liver with a positive ICG Bmax value was selected. Eighteen patients tolerated extensive hepatic resection, such as right trisegmentectomy, extended right lobectomy, extended left lobectomy, or left lobectomy. However, prolonged jaundice was observed postoperatively in five of the six patients with 2-h excretion rates of less than 25% and who had undergone extended right lobectomy. One patient on whom extended right lobectomy had been performed died because of postoperative hepatic failure. His ICG Bmax value was +0.6 and his 2-h excretion rate was very low (3%). ICG Bmax and the 2-h excretion rate in the bile reflected well the degree of separate hepatic dysfunction in patients with biliary obstruction at the hepatic confluence. If ICG Bmax value is more than +1.0, resection of more than two segments, such as trisegmentectomy or extended hepatic lobectomy, may be tolerated, and if the ICG Bmax value is positive, hepatic lobectomy may be tolerated. ICG Bmax and 2-h excretion rate in bile are useful indicators of hepatic functional reserve of the separate lobes of the liver in patients with biliary obstruction at the hepatic hilus.

Purpose The purpose of this study was to investigate the association between internal carotid artery (ICA) stenosis and intramural location and size of calcification at the ICA origins and the origins of the cervical arteries proximal to the ICA. Method A total of 1139 ICAs were evaluated stenosis and calcification on the multi-detector row CT angiography. The intramural location was categorized into none, outside and inside location. The calcification size was evaluated on the 4-point grading scale. The multivariate analyses were adjusted for age, serum creatinine level, hypertension, hyperlipidemia, diabetes mellitus, smoking and alcohol habits. Results Outside calcification at the ICA origins showed the highest multivariate odds ratio (OR) for the presence of ICA stenosis (30.0) and severe calcification (a semicircle or more of calcification at the arterial cross-sectional surfaces) did the second (14.3). In the subgroups of >70% ICA stenosis, the multivariate OR of outside location increased to 44.8 and that of severe calcification also increased to 32.7. Four of 5 calcified carotid plaque specimens extracted by carotid endarterectomy were histologically confirmed to be calcified burdens located outside the internal elastic lamia which were defined as arterial medial calcification. Conclusions ICA stenosis was strongly associated with severe calcification located mainly outside the carotid plaque. Outside calcification at the ICA origins should be evaluated separately from inside calcification, as a marker for the ICA stenosis. Additionally, we found that calcification at the origins of the cervical arteries proximal to the ICA was significantly associated with the ICA stenosis.

Introduction CD151 is a member of the tetraspanin family, which interacts with laminin-binding integrins and other tetraspanins. CD151 is involved in several pathologic activities associated with tumor progression, including metastasis and angiogenesis. The aim of this study was to clarify the clinical use of CD151 expression in gallbladder cancer (GBC). Methods Forty-five patients with GBC who had undergone operative treatment were enrolled in this study. Expressions of CD151 in the resected GBC specimens were evaluated with anti-CD151 antibody. The patients were divided into positive and negative groups according to CD151 expression: CD151-positive group ( n = 26) and CD151-negative group ( n = 19). Clinicopathologic factors, including Ki-67 and matrix metallopeptidase 9, also were compared between the two groups. Results CD151-positive expression was 58% and correlated with poorer prognosis; 5-year survival of CD151-positive and CD151-negative groups was 29% and 78%, respectively ( P = .006). CD151 expression also correlated with lymphatic invasion and curability. Multivariate analysis revealed that CD151-positive expression was an independent prognostic factor (hazard ratio 2.97, P = .02). In addition, CD151 expression correlated with matrix metallopeptidase 9 expression ( P Conclusion Those findings suggested that CD151-positive expression might be a potential prognostic indicator and one of the target molecules for the regulation of tumor metastasis for patients with GBC.

Bronchogenic cyst in the retroperitoneum is rare and only 5 cases including this case have been reported in Japan. A 56-year-old woman was admitted to the hospital because of an epigastric dull pain. Abdominal computed tomography, magnetic resonance imaging and ultrasonography showed a retroperitoneal cystic tumor but the original organ was not defined. Extirpation of the tumor was performed. The extirpated tumor was 10×7.5×3.5 cm in size and contained about 160 ml of viscous and grayish white fluid. Histologically, ciliated columnar epithelia with the seromucous glands and cartilage were observed. The definite diagnosis of bronchogenic cyst was made. Postoperative course was uneventful and the patient has been in good health without any signs of recurrence, as of 1 year after the operation.

肝切除後早期の腹水発生関連因子につき検討した.1985年1月から1993年12月までの肝細胞癌肝切除例中77例を対象とし, 術後腹腔ドレーンからの1日最大総排液量が500ml未満をA群 (53例, 68.8%), 500ml以上をB群 (24例, 31.2%) に分類した.両群間 (A vs B) で有意差を認めたものは, 術前因子でChE (0.58±0.21 vs 0.45±0.15ΔpH), ICGRmax (1.15±1.01 vs 0.78±0.42mg/kg/min), 総合的Risk (2.35±0.64 vs 2.65±0.43), 術中因子で手術時間, 出血量, 輸血・輸液量, 術後因子で組織学的肝硬変度であった.両群間で, アプローチ法, 肝阻血法, 阻血時間, 脱転操作の有無, 切除部位・範囲, 切除重量に有意差はなかった.術後大量腹水の発生にはChE, ICGRmax, 総合的Risk, 肝組織の硬変度が重要であり, 長時間手術や術中出血量, 輸血・輸液量の多い症例に好発した.術後管理は, 体液バランスと肝機能保護, 術後合併症予防とその治療が重要と考えられた.

A 70-year-old man who had undergone radical surgery for renal pelvic transitional cell carcinoma 9 months previously developed solitary cerebellar metastasis. Despite neurosurgical removal, the patient died and post-mortem pathological examination revealed microscopic metastatic lesions within microvessels of the lung. No other lesion, including local residual cancer, was detected.

Osteomyelitis due to candida infection is very rare. This paper presents two cases of candida osteomyelitis following esophagectomy, together with a review of the literature. Case 1: A 65-year-old male developed wound infection of the thoracotomy wound, 27 days after esohagogas-trectomy, distal pancreatectomy and splenectomy for an esophageal cancer. Despite several debridement procedures over a six month period, the wound was not improved. Surgical cultures revealed Candida albicans. The patient underwent a partial resection of 5-8th cartilage and extirpation of abscess cavity with combinations of antimycotic therapy, which resulted in complete wound healing. Case 2: A 46-year-old male failed candida osteomyelitis on the left side of the anterior chest wall three months after esophagectomy for an esophageal cancer. He could recover and the wound was improved to cure after-months administration of antimycotic agent and several debridements of the wound. The total parenteral nutrition (TPN) and broad-spectrum antibiotics were given for postoperative care in both patients. These two cases of candida osteomyeritis might be caused by TPN and/or widespread use of antibiotics.

α-Amino [1-14C] isobutyric acid ([14C] AIB) is a non-metabolizable analogue of alanine, the principal amino acid released by muscle in catabolic states and the major gluconeogenic amino acid in the liver. Phosphoenolpyruvate carboxykinase (PEPCK) is a rate-limiting enzyme in gluconeogenesis. Many factors, such as hormones and cytokines, have effect on both uptake of alanine by the liver and the hepatic PEPCK activity. The aim of this study was to evaluate the cooperative effect of recombinant mouse IL-6 (rmIL-6) and recombinant human IL-1 (rhIL-1) with glucagon on [14C]AIB uptake and PEPCK activity in cultured rat hepatocytes. Our data showed that rmIL-6 and glucagon increased [14C]-AIB uptake individually in a dose-dependent manner and had a significant additive effect on the uptake in rat hepatocytes. However, rhIL-1 had no effect on [14C] AIB uptake. Regarding PEPCK, rmIL-6 and rhIL-1 had no effect on the activity of PEPCK in rat hepatocytes. But both rmIL-6 and rhIL-1 significantly inhibited the stimulative effect of glucagon on hepatic PEPCK activity of the rats.

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.

The liver-hanging maneuver (LHM) is a useful technique in major hepatectomy. We made modifications to this technique with special reference to the ligamentum venosum for performing a left hepatectomy (LH). The aim of this study was to clarify the usefulness of our new technique. Between August 2007 and May 2009, five patients underwent LH using our modified LHM and 12 patients underwent LH using a conventional procedure. The two groups were compared in terms of the patient characteristics, preoperative hepatic functions, surgical records, and outcomes. The characteristics and preoperative hepatic function tests were similar between the modified LHM and non-LHM groups. Intraoperative blood loss was significantly reduced in the modified LHM group compared with the non-LHM group (193 ± 133 vs. 375 ± 167 ml, P