Search

Objective Enteral administration of synbiotics has been reported to be beneficial during various types of surgery, but its clinical value in elderly surgical patients remains unclear. The aim of this study was to quantitatively evaluate the changes in gut microbiota and environment induced by perioperative synbiotic therapy, and to investigate whether it is possible to reduce infectious complications in elderly patients undergoing gastroenterological surgery. Methods Forty-eight patients over the age of 70 y were randomized into a group receiving 7 d of preoperative and 10 d of postoperative synbiotic therapy (S group) and a control group without synbiotic therapy (C group). A fecal sample collected before and after surgery in each group was used for a quantitative evaluation of the microbiota. Results Forty-eight patients completed the trial (25 in the S group and 23 in the C group). Synbiotic therapy significantly maintained the status of Bifidobacterium and Lactobacillus , whereas the number of Enterobacteriaceae , Staphylococcus, and Pseudomonas was significantly decreased. The total organic acid and short-chain fatty acid concentrations were increased, and the pH was markedly decreased, in the S group compared with the C group. The incidence of postoperative infectious complications was 12% in the S group and 36% in the C group, however, the difference did not reach statistical significance ( P = 0.06). A multivariate analysis revealed that only the use of perioperative blood transfusion was an independent risk factor for infectious complications. Conclusions Synbiotic therapy improved the intestinal microbial environment, and might decrease the incidence of infectious complications in elderly surgical patients.

Prolonged hyperbilirubinemia (HB) following living donor liver transplantation (LDLT) can be a risk factor for early graft loss and mortality. However, some recipients who present with postoperative hyperbilirubinemia do recover and maintain a good liver function.The purpose of this study was to investigate the risk factors for hyperbilirubinemia following LDLT and to identify predictors of the outcomes in patients with post-transplant hyperbilirubinemia.A total of 107 consecutive adults who underwent LDLT in Nagasaki University Hospital were investigated retrospectively. The patients were divided into two groups according to postoperative peak serum bilirubin level (HB group: ≥ 30 mg/dl; non-HB group:30 mg/dl). These two groups of patients and the prognosis of patients in the HB group were analyzed using several parameters.Seventeen patients (15.9 %) presented with hyperbilirubinemia, and their overall survival was significantly worse than patients in the non-HB group (n = 90). Donor age was significantly higher in the HB group (P0.05). Of the 17 patients in the HB group, nine survived. The postoperative serum prothrombin level at the time when the serum bilirubin level was30 mg/dl was significantly higher in surviving patients (P0.01).The use of a partial liver graft from an aged donor is a significant risk factor for severe hyperbilirubinemia and a poorer outcome. However, those patients who maintain their liver synthetic function while suffering from hyperbilirubinemia may recover from hyperbilirubinemia and eventually achieve good liver function, thus resulting in a favorable survival.

Background: Outcomes of liver resection for hepatocellular carcinoma (HCC) have improved owing to better surgical techniques and patient selection. Portal hypertension may influence outcome but the preoperative definition and role of portal hypertension are far from clear. The aim of this study was to elucidate the influence of portal venous pressure (PVP) measured directly during surgery on outcomes of liver resection in patients with HCC. Methods: Patients who had resection of HCC between 1997 and 2009, and who underwent direct measurement of PVP immediately after laparotomy were enrolled. These patients were divided into groups with high (at least 20 cmH 2O) and low (less than 20 cmH 2O) PVP. The influence of PVP on overall and recurrence-free survival was analysed and prognostic factors were identified. Results: A total of 177 patients were enrolled, 129 in the low-PVP group and 48 in the high-PVP group. The 5-year overall survival rate (63·7 versus 31 per cent; P < 0·001) and recurrence-free survival rate (52·5 versus 12 per cent; P < 0·001) were significantly higher in patients with low PVP. In multivariable analysis, two or more tumours, tumour diameter at least 5 cm, high PVP, grade B liver damage and Hepatic Activity Index (HAI) grade 7 or more were significant predictors of poorer survival after liver resection. Two or more tumours, tumour diameter at least 5 cm and HAI grade 7 or more were significant predictors of poorer recurrence-free survival. Conclusion: High PVP was associated with poor long-term outcome after liver resection for HCC., British Journal of Surgery, 99(9), pp.1284-1289; 2012

Cell sheet engineering has been noted as a new and valuable approach in the tissue-engineering field. The objective of this study was to explore a procedure to induce hepatic progenitor cells and biliary duct structures in the liver. Sprague-Dawley rat dermal fibroblast (DF) sheets were transplanted into the incised surface of the liver of F344 nude rats. In the control group, an incision was made without transplantation of the DF sheets. Bile duct (BD)-like structures and immature hepatocyte-like cells were observed in the DF sheet transplant sites. These BD-like structures were cytokeratin-8-positive, while the hepatocyte-like cells were both OV-6-positive and α-fetoprotein-positive as well. The proliferation and differentiation of liver progenitor cells were not influenced by hepatectomy. We also transplanted DF sheets transfected with a plasmid encoding the enhanced yellow fluorescent protein target to mitochondria (pEYFP-Mito) by electroporation, and found that the new structures were pEYFP-Mito-negative. We observed new BD-like structures and immature hepatocytes after transplantation of DF sheets onto incised liver surfaces, and clarified that the origin of these BD-like structures and hepatocyte-like cells was the recipient liver. The present study described an aspect of the hepatic differentiation process induced at the site of liver injury.

We report 2 cases of distal arch aneurysm treated by thoracic endovascular aneurysm repair (TEVAR) with the "double-chimney technique." This technique permitted the implantation of a thoracic stent graft in the ascending aorta over the arch branches while preserving perfusion of innominate and left common carotid arteries without debranching bypasses. The procedure is a feasible and less invasive treatment for distal arch aneurysm with a short proximal neck (

Background Since March 2010, we have used a high-speed 3D-image analysis system (SYNAPSE VINCENT) to calculate the graft volume in living donor liver transplantation (LDLT) to replace CT volumetry. The SYNAPSE VINCENT is capable of extracting each vessel territory in the liver and displaying 3D images simply, quickly, and accurately. Therefore, we report here the usefulness of the SYNAPSE VINCENT in pediatric LDLTs in overcoming issues with perfusion area of hepatic venous tributaries in monosegmental grafts. Material/methods The SYNAPSE VINCENT was used in three pediatric patients. In two of these cases, the possibility of monosegmental grafts was assessed when calculating graft volumetry of segment III. Results The graft recipient weight ratio (GRWR) with graft volumetry measurements of the left lateral segment were 1.8-5.6%. GRWR of segment III were 2.3 and 2.0%. Since donor V2, venous branch to segment II and V3, venous branch to segment III were independently branching in one case, the monosegmental graft could be evaluated preoperatively according to the venous perfusion. Conclusions Graft volumetry using the SYNAPSE VINCENT was useful for planning the LDLT operative procedures, especially in infants possibly in need of monosegmental graft.

Severe and life-threatening donor-transmitted human T-cell leukemia virus type 1 (HTLV-1) infections after solid organ transplantation have been reported. However, in HTLV-1-infected recipients, graft and patient survival were not fully evaluated. A total of 140 patients underwent living donor liver transplantation (LDLT). Of these, 47 of 126 adult recipients showed indications of hepatitis C virus (HCV)-related liver disease. The HTLV-1 prevalence rate was 10 of 140 recipients (7.14%) and three of 140 donors (0.02%). In HCV-related LDLT, graft and patient survival was worsened by HTLV-1 infection in recipients (seven cases). The 1-, 3-, and 5-year survival rates in the HCV/HTLV-1-co-infected group were 67%, 32%, and 15%, respectively, and the corresponding rates in the HCV-mono-infected group were 80%, 67%, and 67%, respectively. Only the 5-year survival rates were statistically significant (P=0.04, log-rank method). HTLV-1 infection in recipients is also an important factor in predicting survival in HTLV-1 endemic areas.

BACKGROUND/AIMS All autonomic hepatic nerves are transected following liver transplantation. Recent studies have shown the relationship between an inhibition of autonomic nerves and the accumulation of hepatic progenitor cells (HPC). This study aims to elucidate the influence of hepatic denervation on the accumulation of HPC in the process of liver regeneration. METHODOLOGY Male Sprague-Dawley rats underwent hepatic denervation. Immediately after either denervation (DN group, n=30) or a sham operation (control group, n=30), a two-thirds hepatectomy was performed, and these were sacrificed chronologically. An immunohistochemical analysis of HPC was performed with a mouse monoclonal OV6 type antibody. RESULTS The liver per body weight ratio gradually increased in both groups. On postoperative day (POD) 7, the DN group showed a significantly higher ratio. The HPC expression gradually increased in both groups. The maximal HPC number was observed on POD 7 in the DN group and on POD 3 in the control group. Although there was no significant difference in the HPC numbers between the DN and control group until POD 3, the number of HPC were significantly higher in livers of the denervated rats than in those of the sham operated rats between POD 5 and 14. CONCLUSIONS The hepatic autonomic nerves were thus suggested to play an important role in the accumulation of HPC during liver regeneration in rats.

When right hemi-hepatectomy without middle hepatic vein (MHV) is performed in a living donor (LD), MHV tributaries such as V5 and V8 may be preserved during parenchymal transection to preserve liver function and reduce the damage of the graft. However, no study has so far investigated whether this preservation of MHV tributaries during parenchymal transection has impact on live donor operation or graft function.Of 52 hepatectomies for right lobe LD, MHV tributaries were preserved during hepatic parenchymal transection in 11 cases, while, in the remaining 41 cases MHV tributaries were sacrificed when those were encountered during hepatic parenchymal transection.There was no significant difference in blood loss, operative time, zenith liver enzyme level in a donor and rate of graft failure in a recipient.It was demonstrated that there was no significant effect of outflow preservation from MHV tributaries on LD hepatectomy for right lobe donation and subsequent liver transplantation.

Background/Aims: Indocyanin Green (ICG)-based diagnosis is widely accepted in determination of hepatic resection range, however, we frequently encounter scattered results of preoperative assessment. The aim of this study was to clarify the role of "Tc Galactosyl sialyl albumin (GSA) scintigram in the decision of the resection range. Methodology: One hundred and eighty patients who underwent liver resection were included in this study. The patients were divided according to ICGR15 value as follows; Group 1 (n=100): ICG R15 25%. Each group was divided into two subgroups by their GSA-LHL 0.9 levels and compared with regards to liver function, portal pressure and HAI score of background liver. The frequency of complications was also compared to previous cases without GSA-LHL estimation (n=64). Results: In Groups 2 and 3, the GSA-LHL >0.9 subgroup showed better platelet counts, portal pressure and lower HAI score. In groups of GSA-LHL>0.9, platelet counts showed higher value between below 20% of ICGR15 and above that, while GSA-LHL0.9 compared to previous cases without GSA-LHL estimation. Conclusions: Levels of GSA-LHL reflects severity of portal hypertension in moderately damaged liver preoperatively and could contribute to the decision of the range of resection with low morbidity., Hepatogastroenterology, 58(112), pp.2058-2061; 2012

Introduction Selecting a marginal donor in liver transplantation (LT) remains controversial but is necessary because of the small number of available donors. Case presentation A 46-year-old Japanese woman was a candidate to donate her liver to her brother, who had decompensated liver cirrhosis of unknown origin. Eight years before the donation, she had a mild liver dysfunction that was diagnosed as a hepatitis C virus (HCV) infection (serotype 2). She had received anti-viral therapy with interferon α-2b three times weekly for 24 weeks and had a sustained viral response (SVR). A biopsy of her liver before the donation showed normal findings without any active hepatitis, and her serum was negative for HCV-RNA. Only 67 patients have undergone LT from a cadaveric donor in Japan. The family in this case decided to have living donor LT. A careful selection for the liver graft donation was made; however, since she was the only candidate, we approved her as a living donor. She was discharged nine days after the liver donation. Her liver function recovered immediately. A computed tomography scan showed sufficient liver regeneration one year later. Her brother also had good liver function after LT and had no HCV infection 48 months after surgery and no de novo malignancy. Neither of the siblings has developed an HCV infection. Conclusions A patient with SVR status after interferon therapy might be considered a candidate for living donor LT but only if there are no other possibilities of LT for the recipient. A careful follow-up of the donor after donation is needed. The recipient also must have a very close follow-up because it is difficult to predict what might happen to the graft with post-transplant immunosuppression.

As treatments for acute cellular rejection (ACR) and recurrent hepatitis caused by hepatitis C virus (HCV) are dramatically different, making a precise diagnosis is considered to be essential in patients after liver transplantation. Therefore, we investigated whether immunohistochemical detection of FOXp3, a marker for regulatory T cells (CD4+ CD25+), could be used to differentiate between recurrent hepatitis C and ACR. From a group of 103 cases of living-donor liver transplantation (LDLT), 48 samples were taken via liver biopsy from 20 patients with HCV infection. An initial diagnosis was made based on hematoxylin and eosin staining, which was scored with the hepatitis activity index (HAI) grading, whereas ARC was scored with the rejection activity index (RAI). The FOXp3 immunohistochemical staining on serial specimens was retrospectively analyzed, scoring from 0 to III. The time after LDLT was a median of 270 (range: 14-2000) days, whereas the median number of biopsies per patient was 3 (range: 1-8). The HAI was significantly different between 0 vs. I, and II vs. III, in terms of the FOXp3 score. On the other hand, a significant difference in the RAI was only found between 0 vs. I. In conclusion, FOXp3 may represent a surrogate marker for recurrent HCV infection after LDLT.

Background Although the technique of liver transplantation is well developed, the invasiveness of the operation can be decreased with laparoscopic procedures. Methods We performed elective living donor liver transplantation (LDLT) through a short midline incision combined with hand-assisted laparoscopic surgery (HALS). Nine selected patients with end stage liver disease underwent the procedure between July, 2010 and February, 2011 (median age 60, median Child-Pugh 9, median MELD score 14). Splenectomy was performed simultaneously in 7 cases. The liver (and spleen) were mobilized by a sealing device under a HALS procedure with an 8-cm upper midline incision, followed by explantation of the diseased liver (and spleen) through the upper midline incision which was extended to 12 to 15 cm. Partial liver grafts were implanted through the upper midline incision. Results The median duration of the operation was 741 minutes, the median time needed for anastomosis was 48 minutes, the median blood loss was 3,940 g, and the median liver weight was 866 g. Eight recipients are alive and have good graft function. A difficult implantation for one patient required an additional right transverse incision. When compared with 13 recent liver recipients who underwent LDLT with a regular Mercedes-Benz-type incision, no clinically relevant drawbacks of the HALS hybrid procedure were observed. Conclusion We have shown the feasibility and safety of LDLT performed through a short midline incision without abdominal muscle disruption with the aid of HALS.

Transplantation, 97(9), pp.e52-e53; 2014

Although hepatocyte transplantation holds great promise, most of the transplanted hepatocytes fail to proliferate in the liver without any manipulation of the host. Previous studies have shown that the replacement of the host liver cells with transplanted hepatocytes, called "liver repopulation", requires a combination of proliferative stimuli to the transplanted hepatocytes and suppression of the host hepatocytes. This study explored whether liver repopulation could be achieved by hepatocyte transplantation in a chemically and surgically induced-liver failure model in the rat.Dipeptidyl peptidase IV-positive (DPPIV +) Fisher rats were used as donor and syngeneic DPPIV-deficient (DPPIV-) rats served as recipient. The recipient rats were treated with carbon tetrachloride (CCl4) for 4 weeks followed by a 68% partial hepatectomy (PH) and transplantation of the hepatocytes (HT). Five groups were established based on the influence of specific factors including CCl4, PH, and HT. The liver regeneration rates were evaluated by the liver weight/body weight (LW/BW) ratio. The liver repopulation rates were determined by the formula; (DPPIV+ cell counts/all cell counts) ×100%.The liver regeneration rates were 3.5 and 2.6 in the rats with CCl4+PH, and PH alone, respectively (P0.01). In the rats with CCl4+PH, DPPIV positive cell clusters appeared in the host liver parenchyma 7 days after HT (day 7), exhibiting continuous proliferation up to day 28 (The liver repopulation rates were 1.1% and 13.4%, respectively, p0.05).Liver repopulation by hepatocyte transplantation was therefore found to be possible in partially hepatectomized rats under the continuous exposure to regulated doses of CCl4.

BACKGROUND/PURPOSE: Early identification and treatment of fungal infections is essential for recipients of liver transplants, but the sensitivity of surveillance culture is insufficient. Measurement of the serum level of β-D: -glucan is a rapid diagnostic strategy for invasive fungal infection. We aimed to evaluate the significance of serum β-D: -glucan levels in transplant recipients after living donor liver transplantation (LDLT). METHODS: We retrospectively analyzed the clinical and laboratory data of 100 consecutive adult transplant recipients after LDLT performed between August 1997 and August 2009. RESULTS: Seventy-one had high serum β-D: -glucan levels (>20pg/ml) after LDLT. Nearly half (47.2%) of the episodes of increase occurred within the first 5days after surgery. The mortality rate of the recipients with high serum β-D: -glucan levels was similar to that of the recipients without high levels. However, in terms of the time line of increase, the recipients with high serum β-D: -glucan levels from 15days onward after surgery showed a significantly higher mortality rate than those with high levels before 15days after surgery (33.3 and 4.3%, respectively; p, Journal of hepato-biliary-pancreatic sciences, 18(3), pp.432-435; 2011

Control of infection is important in liver transplant patients under immunosuppressive conditions. In particular, invasive fungal infection is often fatal if diagnosis and therapy are delayed. The aim of this study was to analyze the incidence of fungal colonization and infection after living donor liver transplantation (LDLT).Retrospective analysis was performed with 60 consecutive adult recipients of LDLT.Fungi were isolated from specimens of 16 (26.7%) patients after LDLT. All the fungi were Candida species. One patient for whom Candida species were isolated in ascites and blood was complicated with systemic methicillin-resistant Staphylococcus aureus and cytomegalovirus infection. In the univariate analysis, fungal carriage before surgery (p = 0.01) was associated with fungal isolation after LDLT. In the multivariate analysis, fungal carriage was found to be an independent predictor of fungal isolation (odds ratio: 15.7, p = 0.03). Of the 60 recipients, 16 (26.7%) showed serum levels of beta-D glucan above 60 pg/ml after surgery. Among these, 4 died and were all complicated with severe bacterial infection.Preoperative fungal carriage was associated with fungal isolation after LDLT. If fungal infection was suspected after LDLT, along with treatment against fungi, control of complicated infections with other pathogens to be simultaneously considered.

AIM: To elucidate the metabolism and the effect of the cyclosporin A (CyA) as a representative immunosuppressive drug used in transplantation in a partially hepatectomized rat model. METHODS: CyA was administered to rats that underwent a 70% hepatectomy. These rats were randomly assigned into three groups according to the dose of CyA administration as follows; (group 1) water, (group 2) 5 mg/kg CyA, (group 3) 10 mg/kg CyA. On postoperative days-1, 3, 7 and 14, the rats were killed to analyze the serum concentration of CyA, the liver regeneration ratio, biochemical or histological markers, and mRNA expression using reverse transcriptase-polymerase chain reaction method to determine albumin and cytochrome p450 expression. RESULTS: The serum concentration of CyA in group 3 was significantly higher than group 2 during liver regeneration. CyA enhanced the liver regeneration in a dose dependent manner. The mRNA expression associated with CyA metabolism was significantly decreased on day 14, while preserving the albumin producing activity. CONCLUSION: These data indicate that the p-450 activity required to metabolize the CyA may be reduced during regeneration of the remnant liver after a hepatectomy, which may, therefore, be linked to difficulty in controlling the optimal dose of CyA during early period of LDLT.

E-cadherin (E-cad) is a type of adhesion molecule, and recent studies have demonstrated a correlation between its expression in tumor lesions and the recurrence of HCC. Serum levels of soluble E-cad are significantly elevated in patients with several types of cancer. The authors evaluated the significance of the serum level of soluble E-cad as a predictor of early recurrences (intrahepatic or extrahepatic metastasis) of HCC after a curative resection.The concentrations of soluble E-cad in the serum of 25 HCC patients before surgery and 12 healthy subjects were measured using a sandwich enzyme-linked immunosorbent assay. The hepatic expression of E-cad was examined by immunohistochemical staining.The median serum soluble E-cad levels were significantly elevated in HCC patients before surgery in comparison to those in healthy subjects (10,759 ng/mL vs. 5,798 ng/mL, p0.05). The patients in the high serum soluble E-cad group experienced a higher incidence of early recurrence (p0.05). The levels of expression of E-cad in HCC lesions were not related to the serum levels of soluble E-cadherin.The study demonstrated that serum soluble E-cad levels were elevated in patients with HCC, and high serum soluble E-cadherin (or = 8,000 ng/ml) was associated with early recurrence or extrahepatic metastasis. Serum soluble E-cad may therefore be a potential prognostic marker for HCC.

This report presents a case of portal vein thrombosis possibly caused by anastomotic stricture after living-donor liver transplantation. The patient underwent systemic thrombolytic therapy with tissue plasminogen activator and subsequent balloon dilatation of the stenotic lesion, and both were successful. These procedures allowed the patient to receive antiviral therapy to improve the pancytopenia, leading to a sustained virological response.

Recently we reported that signal transmission of interferon is more suppressed by tacrolimus (Tac) than cycrosporine (CyA). Therefore, although CyA might be beneficial immunosuppressive drug after liver transplantation (LT) on interferon therapy against hepatitis C virus, it is hesitated because of the risk for provocation of rejection. Herein initial outcome of our strategy, i.e. intentional conversion from Tac to CyA during preemptive interferon therapy after living donor LT (LDLT) was reported.Of 62 patients who had undergone LDLT in Nagasaki University Hospital between 1997 and November 2006, 16 patients showed indications for hepatitis C-related liver cirrhosis. The median follow-up period was 15 months. Tac was used for all patients as induction therapy combined with steroids tapering.In 11 out of 16 cases (68.8%), preemptive Pegylated (Peg)-IFN-alpha 2b+Ribavirin therapy was initiated. When Peg-IFN-alpha 2b+Ribavirin therapy was commenced, Tac-to- CyA conversion was done. The median period of conversion from Tac to CyA was 1.5 month after LDLT. After the conversion, ACR occurred in one case. Out of 11 patients, 3 patients (21.4%) showed early viral response (VR) at 3 months, 2 showed end-treatment response at 48 weeks (14.3%) and 3 showed sustained VR (21.4%).Intentional conversion from Tac to CyA can be safely performed without increasing the risk of ACR.

BACKGROUND/PURPOSE: While lipiodolized transarterial chemoembolization (lip-TACE) is effective for treating unresectable hepatocellular carcinoma (HCC), its effect for treating recurrent HCC after curative liver resection needs to be clarified. METHODS: Of 163 patients who had undergone curative liver resection between 1992 and December 2003, 65 patients (39.8%) had recurrent HCC in the liver without extrahepatic recurrence and were indicated for lip-TACE. The overall survival rate after lip-TACE was calculated, and its correlation with factors such as the histology of the primary HCC and background noncancerous tissue were analyzed. RESULTS: The overall survival rates after lip-TACE after the detection of the first recurrent HCC were 82.6%, 44.5%, and 24.8% at 1, 3, and 5 years, respectively. The factors affecting patient survival after lip-TACE were microscopic portal venous involvement of HCC at liver resection, grade of inflammation in the noncancerous liver parenchyma, and recurrence within 1 year after the initial liver resection. Multivariate analysis showed that the period between the resection and first recurrence had the highest hazard ratio. CONCLUSIONS: Lip-TACE is a reasonable procedure for treating recurrent HCC in selected patients who are not eligible for hepatic re-resection. When HCC recurred within 1 year from the primary liver resection, the effect of lip-TACE on patient survival was limited., Journal of hepato-biliary-pancreatic surgery, 15(6), pp.627-633; 2008

A 54-year-old woman was admitted to our hospital following the diagnosis of decompensated liver cirrhosis with hepatitis C. She underwent living-donor liver transplantation, performed using the left hepatic lobe with the middle hepatic vein donated by her husband. After the transplantation, the patient suffered from massive ascites with liver dysfunction. Computed tomography demonstrated stenosis of the suprahepatic inferior vena cava (IVC) with focal collection of fluid. A second laparotomy was performed 19 days after the transplantation. When the encapsulated localized ascites on both sides of the IVC was opened, the ascites was flushed away. Subsequently, the grafted liver was easily mobilized and it was placed in the natural position without any tension, and the pressure gradient of the IVC was improved. Herein, we report a very rare case of compression stenosis of the IVC resulting in Budd-Chiari syndrome caused by localized encapsulated ascites., Journal of hepato-biliary-pancreatic surgery, 15(5), pp.528-530; 2008

Biliary obstruction is rarely caused by a foreign body. This report describes the case of a 60-year-old Japanese man with jaundice caused by an impacted shrapnel splinter in the common bile duct (CBD) that had migrated from the right thoracic cavity 36 years after initial injury. Biochemical data showed a total bilirubin level of 4.2 mg/dl with a direct bilirubin level of 3.1 mg/dl, an alanine aminotransferase level of 24 IU/l, and an alkaline phosphatase level of 18.5 KA units. It was serially documented that the shrapnel had migrated toward the diaphragm, then burrowed into the liver, settling in the CBD, and causing obstructive jaundice. Choledochotomy and T-tube drainage was performed and the postoperative course was uneventful. To our knowledge, this is the first case report of this type of occurrence in the Japanese literature. Although there are few reports of combat injury in Japan, this diagnosis should be considered in the evaluation of any patient with jaundice who has suffered a previous chest wound involving a foreign body.

We herein present a case of attenuated familial adenomatous polyposis (AFAP) with advanced rectal cancer in a 16-year-old boy. His mother and younger brother both had subcutaneous soft tissue tumors in the back and sparse-type colorectal polyposis. His mother also had dental anomalies and gastric fundic gland polyposis. The patient was admitted to our hospital for investigation of bloody stools. Barium enema and colonofiberscopy revealed advanced rectal cancer and sparse (

Title Laparoscopic Middle Pancreatectomy under a Pancreatic Duct-Navigation Surgery Author(s) Kitasato, Amane; Adachi, Tomohiko; Inokuma, Takamitsu; Tajima, Yoshitsugu; Kanematsu, Takashi; Kuroki, Tamotsu Citation Hepato-Gastroenterology, 59(120), pp.2400-2402; 2012 Issue Date 2012-11 URL http://hdl.handle.net/10069/31336 Right © H.G.E. Update Medical Publishing S.A. NAOSITE: Nagasaki University's Academic Output SITE

s / Pancreatology 14 (2014) S1eS129 S113 min (168-512)/316 min (238-376), 443 gr (5-3250)/96 gr (9-210), and 16 days (8-29)/16 days (5-24), respectively. There was no grade B or C pancreatic fistula in both procedures. The postoperative maximum platelet counts in WT/SVP were 36.3/10.9 104/ml. Five patients (28%) with splenic partial infarction and 2 patients (11%) with gastric varices in WT were observed without any treatments. In SVP, There were no complications in the splenic circulation. No local recurrences were seen in both procedures. Conclusion: Two procedures of LSPDP for benign and low-grade malignant tumors are safe and effective.

A liver hanging maneuver is currently being applied for various types of hepatectomies. The most difficult and important step of this technique is to encircle the liver with tape that is passed between the liver and the inferior vena cava, using a blind dissection. This report describes a secure technique for taping utilizing a surgical probe., Surgery Today, 38(12), pp.1155-1156; 2008

The right gastroepiploic artery (RGEA) has been considered a fair alternative choice for a coronary bypass graft. However, after such nonanatomical anastomosis, it is difficult to plan abdominal surgery without endangering the critical arterial supply. To date, gastrectomies and pancreatoduodenectomies have been reported in patients with RGEA grafts for coronary bypass. We recently performed living donor liver transplantation (LDLT) in a patient who had previously undergone coronary bypass surgery using RGEA 3 years before the LDLT. This is the first case of LDLT after coronary bypass using RGEA. We report our two-stage explantation of the cirrhotic liver without any injury to the RGEA. The patient was a 63-year-old man suffering from end-stage liver failure and persistent cholangitis due to primary sclerosing cholangitis in May 2007. LDLT was indicated, and preoperative angio-computed tomography was performed and revealed that the patent RGEA graft was located on the left lobe of the cirrhotic liver (Fig. 1A). The LDLT was scheduled on May 28, 2007, with the attendance of a cardiac surgeon and full monitoring of cardiac function, including transesophageal ultrasound. Laparotomy showed that the RGEA was on the left lobe of the cirrhotic liver (Fig. 1B). In order to liberate the RGEA, the left lateral segmentectomy was performed first with the Cavitron ultrasonic surgical aspirator system (CUSA; Valley-Lab, Boulder, CO) and saline-linked cautery (Dissecting Sealer DS 3.0, Tissue Link Medical, Inc., Dover, NH) with minimal blood loss (Fig. 1B,C). Subsequently, the remnant right lobe of the liver was explanted without a spastic event of the RGEA being caused; a left lobe graft from a living donor was then implanted. The RGEA was placed on the dorsal side of the graft because this was the natural position of the RGEA (Fig. 1D). No cardiac event occurred throughout the LDLT, with total blood loss of 1900 g during a total operative time of 1015 minutes. The patient’s postoperative course was uneventful, and he was discharged from our hospital on the thirty-first day after the LDLT. As of this writing, he has been doing well for 8 months since the LDLT. Performing LDLT in patients after previous abdominal surgery is a therapeutic challenge. In particular, the gastroepiploic artery used for coronary arterial bypass is a cumbersome entity because damage to the artery can cause significant consequences for the patient, including cardiac infarction. We performed two-stage explantation of the liver because it was impossible to mobilize the cirrhotic liver with the RGEA in place as the RGEA was present on the left lobe of the liver. After we recognized the situation through a preoperative three-dimensional recon

Received November 25, 2007; accepted January 20, 2008.A57-year-oldfemalewasdiagnosedwithhepatocellularcarcinoma associated with hepatitis C virus–related cir-rhosis. She underwent ablation therapy several times,including 4 repeated courses of percutaneous ethanolinjection, and was finally referred to our hospital forliver transplantation. During the preoperative evalua-tion, a huge extrahepatic portal vein aneurysm (PVA)and mural thrombosis were detected on computed to-mographic angiography and magnetic resonance imag-ing angiography (Fig. 1). Massive ascites and a recana-lized umbilical vein were also noted. She underwentliving donor liver transplantation using her daughter’sright lobe graft. During surgery, the confluence of thesuperior mesenteric vein and splenic vein seemed to benormal and intact, so the whole PVA was resected, andthe mural thromboses were removed. Thereafter, directend-to-end anastomosis between the recipient portalvein and graft portal vein was successfully accom-plished without tension. The postoperative course wasuneventful until she developed portal vein thrombosisdue to anastomotic stenosis 1 year after the transplan-tation. The complication was successfully reversed bysystemic thrombolytic therapy using recombinant tis-sue plasminogen activator combined with subsequentpercutaneous transhepatic balloon dilatation. Sincethen, the patient has been doing well with normal liverfunction for the past 2 years.Abnormality of the portal vein is often observed inliver transplant candidates but mainly as stenosis orthrombosis in chronic diseases.

Accordingly, we should cutthe bile duct as close as possible to the commonhepatic duct, but biliary stricture in the remnant liverof the donor is a great concern. To overcome theseproblems, we describe our technical inventions forsafe and accurate bile duct division during living do-nor right hepatectomy.During hilar dissection, the right hepatic artery andright portal vein are fully exposed and isolated fromthe hilar plate. At the final step of subsequent paren-chymal transection, the right hilar plate is fully ex-posed and encircled with radiopaque marker fila-ment, which is obtained from surgical gauze (Fig. 1).Intraoperative cholangiography is then performed viaa catheter placed in the cystic duct (Fig. 2A). C-armfluoroscopy is adapted during this procedure to en-able us to check the optimal cutting point of the bileduct, which is made clear by pulling the filament andadjusting the accurate angle (Fig. 2B). The right hilarplate including the right hepatic duct is then sharplydivided with scissors, and the stump of the remnantbile duct is closed with continuous 6-0 absorbablemonofilament sutures ([Polydioxanone] Suture II,Ethicon, Somerville, NJ). Cholangiography with C-arm fluoroscopy is performed again to check the bil-iary leakage or stricture in the remnant bile duct (Fig.2C). The right liver graft is then removed after theright hepatic artery, portal vein, and hepatic veinhave been divided (Fig. 2D).Of 54 living donor hepatectomies from August 1997to December 2005, 38 underwent right hepatectomy,and the present procedure was adapted for use in thelast 10 cases. Compared to the first 28 cases withordinary cholangiography, the incidence of multipleducts in the graft was significantly reduced (3/10 vs.20/28, respectively

Title Colonic explosion by electronic cautery during living donor liver transplantation Author(s) Tanaka, Takayuki; Eguchi, Susumu; Takatsuki, Mitsuhisa; Muraoka, Izumi; Tomonaga, Tetsuo; Soyama, Akihiko; Hidaka, Masaaki; Kanematsu, Takashi Citation ANZ Journal of Surgery, 81(9), pp.657; 2011 Issue Date 2011-09 URL http://hdl.handle.net/10069/27226 Right © 2011 The Authors. ANZ Journal of Surgery © 2011 Royal Australasian College of Surgeons NAOSITE: Nagasaki University's Academic Output SITE