Prevention of esophageal strictures after endoscopic submucosal dissection

Endoscopic mucosal resection(EMR) and endoscopic submucosal dissection(ESD) have recently been accepted as less invasive methods for treating patients with early esophageal cancers such as squamous cell carcinoma and dysplasia of Barrett's esophagus.However,the large defects in the esophageal mucosa often cause severe esophageal strictures,which dramatically reduce the patient's quality of life.Although preventive endoscopic balloon dilatation can reduce dysphagia and the frequency of dilatation,other approaches are necessary to prevent esophageal strictures after ESD.This review describes several strategies for preventing esophageal strictures after ESD,with a particular focus on anti-inflammatory and tissue engineering approaches.The local injection of triamcinolone acetonide and other systemic steroid therapies are frequently used to prevent esophageal strictures after ESD.Tissue engineering approaches for preventing esophageal strictures have recently been applied in basic research studies.Scaffolds with temporary stents have been applied in five cases,and this technique has been shown to be safe and is anticipated to prevent esophageal strictures.Fabricated autologous oral mucosal epithelial cell sheets to cover the defective mucosa similarly to how commercially available skin products fabricated from epidermal cells are used for skin defects or in cases of intractable ulcers.Fabricated autologous oralmucosal-epithelial cell sheets have already been shown to be safe.

Hemi-hepatectomy in pediatric patients using two-surgeon technique and a liver hanging maneuver

AIM: To evaluate the efficacy of the two-surgeon technique with the liver hanging maneuver (LHM) for hepatectomies in pediatric patients with hepatoblastoma. METHODS: Three pediatric patients with hepatoblastoma were enrolled in this study. Two underwent right hemi-hepatectomies and one underwent a left hemihepatectomy using the two-surgeon technique by means of saline-linked electric cautery (SLC) and the Cavitron Ultrasonic Surgical Aspirator (CUSA; Valleylab, Boulder, CO) and the LHM. RESULTS: The mean operative time during the parenchymal transections was 50 min and the mean blood loss was 235 g. There was no bile leakage from the cut surface after surgery. No macroscopic or microscopic-positive margins were observed in the hepatic transections. CONCLUSION: The two-surgeon technique using SLC and CUSA with the LHM is applicable to even pediatric patients with hepatoblastoma.

Immunological milieu in the peritoneal cavity at laparotomy for gastric cancer

AIM:To investigate the immunological repertoire in the peritoneal cavity of gastric cancer patients.METHODS:The peritoneal cavity is a compartment in which immunological host-tumor interactions can occur.However,the role of lymphocytes in the peritoneal cavity of gastric cancer patients is unclear.We observed 64 patients who underwent gastrectomy for gastric cancer and 11 patients who underwent laparoscopic cholecystectomy for gallstones and acted as controls.Lymphocytes isolated from both peripheral blood and peritoneal lavage were analyzed for surface markers of lymphocytes and their cytokine production by flow cytometry.CD4+CD25high T cells isolated from the patient's peripheral blood were co-cultivated for 4 d with the intra-peritoneal lymphocytes,and a cytokine assay was performed.RESULTS:At gastrectomy,CCR7 -CD45RA-CD8+ef-fector memory T cells were observed in the peritoneal cavity.The frequency of CD4+CD25 high T cells in both the peripheral blood and peritoneal cavity was elevated in patients at advanced stage[control vs stage Ⅳin the peripheral blood:6.89(3.39-10.4)vs 15.34(11.37-19.31),P<0.05,control vs stageⅣin the peritoneal cavity:8.65(5.28-12.0)vs 19.56(14.81-24.32),P<0.05].On the other hand,the suppression was restored with CD4+CD25high T cells from their own peripheral blood.This study is the first to analyze lymphocyte and cytokine production in the peritoneal cavity in patients with gastric cancer.Immune regulation at advanced stage is reversible at the point of gastrectomy.CONCLUSION:The immunological milieu in the peritoneal cavity of patients with advanced gastric cancer elicited a Th2 response even at gastrectomy,but this response was reversible.

Comparison between bioartificial and artificial liver for the treatment of acute liver failure in pigs

AIM: To characterize and evaluate the therapeuti efficacy of bioartificial liver (BAL) as compared to tha of continuous hemodiafiltration (CHDF) with plasma exchange (PE), which is the current standard therapy fo fulminant hepatic failure (FHF) in Japan. METHODS: Pigs with hepatic devascularization were divided into three groups: (1) a non-treatment group (NT; n = 4); (2) a BAL treatment group (BAL; n = 4) (3) a PE + CHDF treatment group using 1.5 L of norma porcine plasma with CHDF (PE + CHDF, n = 4). Our BA system consisted of a hollow fiber module with 0.2 μm pores and 1 x 1010 of microcarrier-attached hepatocyte inoculated into the extra-fiber space. Each treatment wa initiated 4 h after hepatic devascularization. RESULTS: The pigs in the BAL and the PE + CHD groups survived longer than those in the NT group. The elimination capacity of blood ammonia by both BAL and PE + CHDF was significantly higher than that in NT Aromatic amino acids (AAA) were selectively eliminated by BAL, whereas both AAA and branched chain amino acids, which are beneficial for life, were eliminated by PE + CHDF. Electrolytes maintenance and acid-base balance were better in the CPE + CHDF group than that in the BAL group. CONCLUSION: Our results suggest that PE + CHDF eliminate all factors regardless of benefits, wherea BAL selectively metabolizes toxic factors such as AAA However since PE + CHDF maintain electrolytes and acid-base balance, a combination therapy of BAL plu CPE + CHDF might be more effective for FHF.

Clearance of hepatitis C virus after living-donor liver transplantation in spite of residual viremia on end date of interferon therapy before transplantation

Interferon (IFN) therapy is the only treatment strategy for hepatitis C virus (HCV) infection after liver transplantation (LT), but prophylactic and treatable IFN therapy after LT has been shown to be insufficient due to the adverse effects of IFN and rivabirin. In this paper, we describe the disappearance of HCV after LT without IFN therapy in the presence of residual viremia on the day of LT. We herein report our findings since this is considered an important case for the anti-HCV strategy of post LT. A 60-year old woman with LC and HCC was referred to Nagasaki University Hospital in August 2004. After she underwent LT on February 18, 2005, we injected peg- IFN-α-2a the 11th time at 18 wk and HCV-RNA was still positive in the serum at LT. The serum HCV-RNA was negative one month after operation and subsequently dissolved 15 mo after operation without IFN therapy. As a result, we speculate that if HCV-RNA is positive while HCV core antigen is negative before LT, then it may lead to clearance of HCV after LT. Therefore long acting peg-IFN- α-2a is thus considered a potentially effective agent for the treatment of HCV-related cirrhosis before LT.

Case of plasmablastic lymphoma of the sigmoid colon and literature review

Plasmablastic lymphoma(PBL) is a rare form of nonHodgkin's lymphoma that is associated with human immunodeficiency virus(HIV) infection. Although PBL is most commonly observed in the oral cavity of HIV-positive patients, it can also be observed at extra-oral sites in HIV-negative patients. This report represents an unusual case of HIV-negative PBL that occurred in the sigmoid colon. This patient had a history of systemic lupus erythematosus and an underlying immunosuppressive state from long term steroid therapy. The lymphoma cells were positive for CD138, kappa light chain restriction and Epstein-Barr virus and negative for CD20/L26, CD3, CD79 a, UCHL1(CD45RO) and cytokeratin(AE1/AE3). The patient died approximately 2 mo after the operation. In the present paper, we review cases of PBL of the colon in HIVnegative patients.

Chronological changes in the liver after temporary partial portal venous occlusion

AIM:To investigate time-dependent changes caused by temporal portal vein obstruction and subsequent reperfusion in the lobe with or without an occluded portal vein.METHODS:The portal vein(PV)of the anterior lobe of the liver of a male Wistar rat(8 wk-old)was obstructed(70%)for 12,24,36 and 48 h,respectively,and models were sacrificed at 48 h after reperfusion(each group:n=10).The histological changes and the status of liver regeneration were compared between a liver biopsy performed on each lobe after temporary obstruction of the portal vein in the same rat liver,and the liver extracted at the time of sacrifice(48 h after reperfusion).RESULTS:With regard to the obstructed lobe,the liver weight/body weight ratio significantly decreased according to obstruction time.On the other hand,in thenon-obstructed lobe,there were no significant differences within each group.The duration of PV occlusion did not seem to be strong enough to introduce liver weight increase.Stimulation of liver regeneration was brought about in the non-occluded lobe by 12-h occlusion,and was sustained even at 48 h after reperfusion.The obstructed lobe atrophied with the passage of time in the obstructed state.However,the proliferating-cell nuclear antigen labeling index also increased at 48 h after reperfusion,and a repair mechanism was observed.CONCLUSION:Temporary blood flow obstruction of the portal vein may become a significant trigger for liver regeneration,even with an obstruction of 12 h.

Metabolism for cyclosporin A during liver regeneration after partial hepatectomy in rats

AIM: To elucidate the metabolism and the effect of the cyclosporin A (CyA) as a representative immuno-suppressive drug used in transplantation in a partially hepatectomized rat model. METHODS: CyA was administered to rats that under- went 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 post- operative days-1, 3, 7 and 14, the rats were killed to analyze the serum concentration of CyA, the liver re- generation ratio, biochemical or histological markers, and mRNA expression using reverse transcriptase-poly- merase 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 associ- ated with CyA metabolism was signifi cantly decreased on day 14, while preserving the albumin producing activity. CONCLUSION: These data indicate that the p-450 ac-tivity required to metabolize the CyA may be reduced during regeneration of the remnant liver after a hepa- tectomy, which may, therefore, be linked to diffi culty in controlling the optimal dose of CyA during early period of LDLT.

A case of mucin producing liver metastases with intrabiliary extension

一个 75 岁的人从结肠癌与肝转移的诊断进入我们的医院。他八年以前为盲肠的癌症经历了正确的半结肠切除术，并且在片断 8 有一个变形的肝肿瘤(S8 ) ，它是通过手术 resected 在起始的操作以后的大约 4 年。从两操作的 resected 标本的组织病理学说的检查与 mucinous 揭示了区分得好的腺癌。在第二操作以后的四个月，计算断层摄影术在残余肝的切割表面表明了低密度的损害。尽管是煽动性的液体的一个手术后的集合被认为，它形成了一种膀胱的配置并且在直径在尺寸增加了到约 5 厘米。与变形癌症的复发的临时诊断， S8 的部分肝切除术被执行。resected 标本的组织学的检查也揭示了粘蛋白的腺癌，它入侵了进胆管，沿着它的上皮代替并且延长。Immunohistochemically，肿瘤房间为 cytokeratin (CK ) 是积极的 20，但是为 CK7 否定。因此，肿瘤从结肠的癌症作为变形腺癌被诊断。颜色的肝转移表面的腺癌有时入侵 Glisson 的三个一组并且沿着胆管成长。

Heparin-induced thrombocytopenia occurring early after living donor liver transplantation:a case report

Background:Thrombocytopenia commonly occurs early after liver transplantation.Heparin,usually administered as anticoagulant ther-apy for thrombosis,a common complication after liver transplantation,may cause heparin-induced thrombocytopenia.Heparin-induced thrombocytopenia is a rare but life-threatening complication,and its diagnosis after liver transplantation is challenging.Case presentation:We report a case of heparin-induced thrombocytopenia after living donor liver transplantation with a good out-come because of early diagnosis and discontinuation of heparin.After liver transplantation,the platelet count usually reaches a nadir on postoperative days 3–5 and gradually recovers.In contrast,heparin-induced thrombocytopenia typically occurs 5–10 days after heparin administration;therefore,if heparin is started intraoperatively,then thrombocytopenia will occur on postoperative days 5–10.Conclusion:Monitoring the trend and timing of thrombocytopenia and detailed examination for thrombosis may help confirm the diag-nosis of heparin-induced thrombocytopenia in the early stage after liver transplantation.

Is there any correlation between Iiver graft regeneration and recipient's pretransplant skeletal muscle mass?-a study in extended Ieft Iobe graft Iiving-donor Iiver transplantation

Background:The end-stage liver disease causes a metabolic dysfunction whose most prominent clinical feature is the loss of skeletal muscle mass(SMM).In living-donor liver transplantation(LDLT),liver graft regeneration(GR)represents a crucial process to normalize the portal hypertension and to meet the metabolic demand of the recipient.Limited data are available on the correlation between pre-LDLT low SMM and GR.Methods:Retrospective study on a cohort of 106 LDLT patients receiving an extended left liver lobe graft.The skeletal muscle index(SMI)at L3 level was used for muscle mass measurement,and the recommended cut-off values of the Japanese Society of Hepatology guidelines were used as criteria for defining low muscularity.GR was evaluated as rate of volume increase at 1 month post-LT[graft regeneration rate(GRR)].Results:The median GRR at 1 month post-LT was 91%(IQR,65-128%)and a significant correlation with graft volume-to-recipient standard liver volume ratio(GV/SLV)(rho-0.467,P<0.001),graft-to-recipient weight ratio(GRWR)(rho-0.414,P<0.001),donor age(rho-0.306,P=0.001),1 month post-LT cholinesterase serum levels(rho 0.397,P=0.002)and pre-LT low muscularity[absent vs.present GRR 97.5%(73.1-130%)vs.83.5%(45.2-110.9%),P=0.041]was noted.Moreover in male recipients,but not in women,it was shown a direct correlation with pre-LT SMI(rho 0.352,P=0.020)and inverse correlation with 1 month post-LT SMI variation(rho-0.301,P=0.049).A low GRR was identified as an independent prognostic factor for recipient overall survival(HR 6.045,P<0.001).Conclusions:Additionally to the hemodynamic factors of portal circulation and the quality of the graft,the metabolic status of the recipients has a significant role in the GR process.A pre-LT low SMM is associated with impaired GRR and this negative impact is more evident in male recipients.

Hepatic resection for hepatocellular carcinoma

Hepatic resection has become the standard treatment of primary liver cancer. Indications for hepatic resection in patients with hepatocellular carcinoma (HCC) vary greatly between Japan and other countries because the clinical practice guidelines for HCC defined by the Japan Society of Hepatology differ from the EASL-EORTC clinical practice guidelines. Hepatic resection is not recommended as a treatment for the patients at Barcelona Clinic Liver Cancer (BCLC) stage B. Otherwise, there are many surgeons/clinicians who believe that not all HCC patients at BCLC stage B should be excluded from an indication for hepatectomy because many reports showed good prognosis after hepatic resection for HCC patients over BCLC stage B. The survival rate is expected to increase with better outcomes of hepatectomy in the future. This paper has described indications for hepatectomy for patients with HCC through comparison of domestic guidelines with overseas guidelines, focusing on their differences.