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ObjectiveLiver biopsy is still needed for fibrosis staging in many patients with non-alcoholic fatty liver disease. The aims of this study were to evaluate the individual diagnostic performance of liver stiffness measurement by vibration controlled transient elastography (LSM-VCTE), Fibrosis-4 Index (FIB-4) and NAFLD (non-alcoholic fatty liver disease) Fibrosis Score (NFS) and to derive diagnostic strategies that could reduce the need for liver biopsies.DesignIndividual patient data meta-analysis of studies evaluating LSM-VCTE against liver histology was conducted. FIB-4 and NFS were computed where possible. Sensitivity, specificity and area under the receiver operating curve (AUROC) were calculated. Biomarkers were assessed individually and in sequential combinations.ResultsData were included from 37 primary studies (n=5735; 45% women; median age: 54 years; median body mass index: 30 kg/m2; 33% had type 2 diabetes; 30% had advanced fibrosis). AUROCs of individual LSM-VCTE, FIB-4 and NFS for advanced fibrosis were 0.85, 0.76 and 0.73. Sequential combination of FIB-4 cut-offs (ConclusionSequential combinations of markers with a lower cut-off to rule-out advanced fibrosis and a higher cut-off to rule-in cirrhosis can reduce the need for liver biopsies.

Objective Liver biopsy is still needed for fibrosis staging in many patients with non-alcoholic fatty liver disease. The aims of this study were to evaluate the individual diagnostic performance of liver stiffness measurement by vibration controlled transient elastography (LSM-VCTE), Fibrosis-4 Index (FIB-4) and NAFLD (non-alcoholic fatty liver disease) Fibrosis Score (NFS) and to derive diagnostic strategies that could reduce the need for liver biopsies. Design Individual patient data meta-analysis of studies evaluating LSM-VCTE against liver histology was conducted. FIB-4 and NFS were computed where possible. Sensitivity, specificity and area under the receiver operating curve (AUROC) were calculated. Biomarkers were assessed individually and in sequential combinations. Results Data were included from 37 primary studies (n=5735; 45% women; median age: 54 years; median body mass index: 30 kg/m2; 33% had type 2 diabetes; 30% had advanced fibrosis). AUROCs of individual LSM-VCTE, FIB-4 and NFS for advanced fibrosis were 0.85, 0.76 and 0.73. Sequential combination of FIB-4 cut-offs (

Background/Aims: Expert technique and special anatomical or physiological knowledge are needed in the field of pancreatic surgery. The establishment of basic policies and operative techniques for pancreaticoduodenectomy (PD) and stepwise training for young pancreatic surgeons are necessary. Methods: We scheduled PD for ampullar, biliary and pancreas carcinoma, and evaluated types of pancreatic anastomosis or results by each operator such as a chief, fellowship and resident doctors (>5 years after graduation). Results: Based on a questionnaire distributed to young residents (n=30), only half of them have experienced PD or PPPD, which was related to operating volume at the hospital. Post-operative complications at the teaching hospital were observed in 50 of 88 patients (56%). Post-operative complications were not significantly correlated with the type of anastomosis; however, duct-to-mucosa anastomosis of the pancreas might decrease pancreatic fistula (0% vs. 26% in pancreaticogastrostomy and 13% in pancreaticojejunostomy without duct-to-mucosa anastomosis). Based on the stepwise education protocol of technique, patient demographics, the surgical records and the post-operative complications were not significantly different between experienced teaching surgeons, fellowship surgeons and senior residents, although the time of operation and anastomosis tended to be longer in resident surgeons (p=0.22). Conclusion: Competent operative techniques for inexperienced surgeons and the achievement of safe resection at each stage are our educational goals for PD., Hepato-Gastroenterology, 57(102-103), pp.1046-1051; 2010

Background/Aims: Pyridinoline cross-linked carboxyterminal telopeptide of type I collagen (1CTP) is a sensitive serum marker for metastatic bone carcinomas and may also be associated with invasiveness of various carcinomas. To clarify the significance of 1CTP in hepato-biliary pancreas malignancies, we examined the relationship between clinicopathological features and serum level of 1CTP. Methodology: The subjects were 75 patients who underwent surgical resections including 27 patients with liver carcinomas, 15 with extra-hepatic biliary carcinomas, 14 pancreatic carcinomas and 19 benign diseases. Results: 1CTP level tended to be higher in the malignant diseases than in benign diseases but this difference was not significant (p=0.065). Compared to benign adenoma, 1CTP level in the malignant diseases was significantly higher (p=0.049). 1CTP level tended to be higher in patients with cholangitis compared to those with no inflammation or benign tumors (p=0.065). 1CTP was not correlated with any tumor markers. 1CTP was not associated with node status and vascular infiltrations. 1CTP level tended to be lower in patients with poor differentiation. Conclusions: Serum level of 1CTP might be a predictive marker for hepatobiliary pancreas malignancies but also reflects the degree of co-existing cholangitis., Hepato-Gastroenterology, 57(101), pp.694-697; 2010

To achieve complete resection of metastatic colonic carcinoma in the liver and lung, thoraco-laparotomy-assisted simultaneous resection was attempted in a 60-year-old male patient who had previously undergone sigmoidectomy for primary sigmoid colon carcinoma. A solitary liver metastasis was observed in segment 7 and a solitary lung metastasis was located in segment 6 of the right lower lung. Simultaneous resection was attempted and, in the left lateral position, a thoraco-laparotomy with oblique incision was made in the right seventh intercostal space. Both tumors could be palpated under a good operative view. A partial hepatectomy was performed followed by a segmental resection of the lung. A chest drainage tube was inserted for two postoperative days. The patient had no remarkable complications including pulmonary complication after surgery and was discharged at day 20 post-operation. For metastatic tumors simultaneously located in the right subphrenic part of the liver and the lower part of the right lung, thoraco-laparoscopy-assisted complete resection is a safe and useful option to achieve curative treatment., Hepato-Gastroenterology, 56(94-95), pp.1362-1365; 2009

Background/Aims: To identify clinical significances of portal vein embolization (PVE) prior to major hepatectomy, we examined clinical parameters and outcome after right hepatectomy in patients who underwent PVE. Methodology: The subjects were 30 patients who underwent PVE (PVE group), and 52 patients (non-PVE), in whom PVE was considered unnecessary, followed by right hepatectomy for hepatobiliary cancer. Results: Total hepatic volume after PVE (1068±268 ml) tended to increase compared with before PVE (p=0.059). After PVE, the change in hemi-liver volume was 8.9±6.0%. Increases in hepatic volume of non-embolized left liver before and at 4 weeks after hepatectomy between the PVE and non-PVE groups were similar. Changes in hepatic volumes before and after PVE were not significantly influenced by background liver disease. After PVE, the functional liver volume (419±185cm 3) was significantly lower than morphological volume (564±165cm3) in the embolized liver (p, Hepato-Gastroenterology, 56(91-92), pp.773-777; 2009

Many causes of biliary stricture are iatrogenic including postoperative complication such as a cholecystectomy. We examined the clinical demographics, surgical records and outcome in 7 patients undergoing biliary surgery between 1994 and 2006. Diseases included gall stone in 6 patients and neuroendocrine tumor of the pancreas head in one. Causes of biliary stricture included bile duct injury during cholecystectomy in 4 patients, and stenosis of hepaticojejunostomy in 3 (Repair of biliary injury in two and reconstruction after pancreaticoduodenectomy (PD) in one). Treatment modalities included surgical resection of stricture and reconstruction in 4 patients, extension by balloon catheter in one, and conservative treatment in two. Six patients have been cured and, however, one patient died of biliary cirrhosis and progressive hepatic failure at 4 years after PD. When improvement by the extension of stricture was not observed, surgical approach should be necessary. Complete resection of stricture and anastomosis between normal bile duct and intestine might be necessary. Indication of placement of metallic stent in stricture was thought to be carefully considered., Hepato-gastroenterology. 56(89), pp.43-46; 2009

BACKGROUND/AIMS: Characteristics of intraductal papillary mucinous neoplasms of pancreas (IPMN) have been clarified by a worldwide survey and meeting. However, the malignant behavior or prognosis of the disease is not always uniform. METHODOLOGY: We examined the clinicopathologic demographics, surgical records and outcome according to degree of histologic malignancy in 18 IPMN patients between 1994 and 2006. RESULTS: Main duct type was observed in 3 patients, branch duct type in 6, and mixed type in 9. Eight of 18 patients (44.4%) had other malignancies, and other synchronous tumors were observed in the adenoma group. CA 19-9 was increased in invasive carcinomas. The size of the main pancreatic duct and cysts were not correlated with degree of malignancy. Mural nodules were more frequently observed in minimally invasive and invasive carcinomas. Segmental resection or observation was selected in the adenoma group; however, combined resection of main vessels was performed in invasive carcinoma groups. Although 3 of 5 patients with invasive carcinomas had a recurrence and poor patient prognosis, recurrence was not observed in other groups. CONCLUSIONS: Surgical results for IPMN were satisfactory; however, it is necessary to determine the operative indication before the carcinoma becomes invasive as such lesions have a poor prognosis., Hepato-gastroenterology, 55(88), pp.2238-2241; 2008

BACKGROUND/AIMS: In the advanced stage of hepatobiliary malignancies, concurrent hepatopancreatoduodenectomy (HPD) is necessary to accomplish curative resection, even though high rates of morbidity and mortality still remain. METHODOLOGY: We examined the surgical records and outcome in 11 patients undergoing HPD. RESULTS: In 11 patients, diseases included bile duct carcinomas in 7 patients, gallbladder carcinomas in 3, and ampullar carcinoma in one. Hemi-hepatectomy with resection of the caudate lobe was performed in 8 patients and resection of segment 4 and 5 of the liver in two. Pancreatoduodenectomy (PD) was performed in 3 patients and pylorus-preserving PD in 8. Curative resection was accomplished in 8 patients. Two patients underwent adjuvant photodynamic therapy because of a cancer-positive margin. Morbidity rate was 36% but no hospital deaths were reported. The tumor recurrence rate was 73% and 8 patients died of cancer. Patient prognosis of gallbladder cancers (12 +/- 1 months) tended to be shorter than in patients with bile duct cancers (19 +/- 11 months) (p=0.15). Three patients with bile duct cancers survived without tumor relapse over 12 months. CONCLUSIONS: Complete surgical resection (R0) by HPD could be safely performed for diseases of the hepatobiliary malignancies, which achieved longer survival in some patients., Hepato-Gastroenterology, 55(86-87), pp.1691-1694; 2008

Background/Aims: Measurement of urinary sulfated bile acid (USBA) level is a simple urine test that reflects the degree of cholestasis in newborns. The aim of this study was to clarify the clinical significances of this test for liver diseases in adults. Methodology: We examined the relationship between USBA level in a urine sample by enzymatic assay and clinical parameters and postoperative complications in 27 patients with hepatobiliary diseases who underwent surgical procedures between 2002 and 2007. Results: Mean USBA in all patients before surgery was 39.8 ± 64.0 μmol/L (median value was 6.6). USBA level was increased in patients with cholestasis. USBA level was significantly correlated with serum total bile acid, total bilirubin level and serum hyaluronic acid level (r=0.850, 0.602 and 0.504, respectively) (p, Hepato-Gastroenterology, 56(90), pp.299-302; 2009