Evaluation of Preoperative Magnetic Resonance Cholangiopancreatography in Acute Cholecystitis to Predict Technical Difficulties in Laparoscopic Cholecystectomy

Magnetic resonance cholangiopancreatography (MRCP) is a non-invasive imaging technique that provides high-quality visualization of the biliary tree, including the gallbladder. This study aimed to evaluate the useful-ness of preoperative MRCP for acute cholecystitis in predicting technical difficulties during laparoscopic chole-cystectomy (LC). A total of 168 patients who underwent LC with preoperative MRCP were enrolled in this study. Patients were divided into two groups according to preoperative MRCP findings: the visualized group (n = 126), in which the entire gallbladder could be visualized; and the non-visualized group (n = 42), in which the entire gallbladder could not be visualized. The perioperative characteristics and postoperative complica-tions of the two groups were retrospectively analyzed. Operation time was longer in the non-visualized group (median 101.5 vs. 143.5 min; p < 0.001). The non-visualized group had significantly more intraoperative blood loss than the visualized group (median 5 vs. 10 g; p = 0.05). The rate of conversion to open cholecystectomy was significantly higher in the non-visualized group (1.6 vs. 9.5%; p = 0.03). In conclusion, patients in the non- visualized group showed higher difficulty in performance of LC. Our MRCP-based classification is a simple and effective means of predicting difficulties in performing LC for acute cholecystitis

Arginine enriched EN after total gastrectomy

The effects of early enteral arginine-rich nutrition (EAN) were analyzed among patients undergoing curative-intent total gastrectomy for gastric cancer. There were 19 patients in this prospective study, all randomly assigned to either a parenteral nutrition (PN) group or an EAN group for the first seven days after surgery. The EAN group received 1.8-fold greater arginine (10.1 g / day) compared with the PN group, which was administered through an enteral tube inserted into the jejunal loop. Both groups were provided almost identical amounts of total amino acids (54 g / day), and the total energy was set at 65% of the total requirement (25 kcal / kg / day). No significant differences were observed between the two groups in postoperative complications, length of hospital stay, oral intake, nutritional status, or body weight. The serum arginine profile was similar in the two groups, as it decreased significantly on postoperative day (POD) 1, and gradually returned to preoperative levels by POD 7. The nitrogen balance remained negative until POD 7 in the PN group, but turned neutral at POD 7 in the EAN group. While we could not confirm body weight loss improvement, these results suggested that early arginine-rich enteral nutrition could improve the nitrogen balance after total gastrectomy

Synchronous Total Occlusion of the Celiac Axis and Superior Mesenteric Artery: An Autopsy Case

Acute mesenteric ischemia (AMI) is often caused by superior mesenteric artery (SMA) embolization. We report a rare case of synchronous celiac axis and SMA embolization in an elderly woman with initially mild abdominal pain. Ultimately, a second contrast-enhanced computed tomography revealed extensive necrosis from the stomach to the transverse colon together with liver ischemia due to hours of occlusion. Multiorgan failure made palliation the only option, and she died the following evening. Autopsy revealed a fragile atherosclerosis-asso-ciated thrombus. Careful examination and repeat diagnostic tests should be performed in patients with mild abdominal symptoms at risk for AMI

Preoperative simulation with a 3-dimensional printed solid model for one-step reconstruction of multiple hepatic veins during living donor liver transplantation

Meticulous preoperative volumetry of the partial liver graft is essential for both assessing the postoperative graft function and to ensure the donor safety in the field of living donor liver transplantation (LDLT).We herein report the case of a 53-year-old patient who underwent LDLT for hepatitis C virusinfected liver cirrhosis complicated with hepatocellular carcinoma. Preoperative 3D images were obtained using a 3D image analysis system to evaluate the graft volume and possible congested volume after implantation in LDLT, which revealed that a large middle hepatic vein drained a vast area in the right lobe. The extended left graft was considered to be small for size of the recipient, with an estimated congested area of 407 ml, which was equivalent to 39% of the donor’s liver volume in the remnant right lobe.We decided to use a right lobe graft with the middle hepatic vein, because the volume was considered to be sufficient. A preoperative contrast-enhanced CT scan revealed a distance of 2 cm between the donor’s right hepatic vein and middle hepatic vein at the estimated Cantlie line. Because of the location, we planned to use autologous portal vein Y-graft interposition for the hepatic venous anastomosis. Three-dimensional printed solid models of the donor’s right lobe graft and the Y-graft from the recipient’s portal vein were also made for preoperative simulation using the Vincent program.Based on the estimation, we were able to evaluate whether to reconstruct the middle hepatic vein tributaries or anomalous hepatic veins in LDLT. The 3D solid model was effective for preoperative simulation and planning, which made it easy to imagine the reconstructed shape of the anastomosis with appropriate spatial perception

Results of laparoscopic subtotal cholecystectomy by laparoscopic linear stapler in difficult cases with severe cholecystitis

Laparoscopic subtotal cholecystectomy (LSC) has been recognized as a safe and feasible alternative surgical procedure for a difficult laparoscopic cholecystectomy (LC) with severe inflammation in Calot’s triangle. We compared the surgical outcomesof cholecystectomy for acute cholecystitis between standard LC and LSC using laparoscopic linear stapler. 172 patients were diagnosed as acute cholecystitis, among them, 16 patients who underwent LSC and other 156 patients who underwent standardLC were enrolled in this study. The severity grading of acute cholecystitis in LSC group was significantly higher than LC group. Operation time was longer in the LSC group than LC group. LSC had significantly more intraoperative blood loss compared to LC. However, there was no significant difference in the postoperative complications between two groups. LSC using laparoscopic linear stapler contributes surgeons avoid common bile duct injury in difficult LC

A case of surgical resection for well-differentiated squamous cell carcinoma arising in a ciliated hepatic foregut cyst

Ciliated hepatic foregut cysts (CHFC) are extremely rare, and most are benign cysts of the liver arising from remnants of the embryonic foregut. CHFC is usually found incidentally and as mostly asymptomatic cysts. We report squamous cell carcinoma (SCC) arising in a CHFC in a 50-year-old Japanese woman. She consulted our hospital for upper abdominal pain.A computed tomography and an ultrasound showed a cystic region including calcification and a solid mass in segment 4 of the liver. Left hepatectomy, B6 bile duct resection, and biliary-jejunal anastomosis were performed. Microscopic examination revealed that part of the cyst was lined by a characteristic ciliated pseudostratified columnar epithelium surrounding a connective tissue, a slightly thick fibrotic smooth muscle stromal layer, and an outer fibrous capsule. The cyst wall contained a low-papillary mural nodule showing atypical squamous hyperplasia with high-grade dysplasia. Stromal invasion was identified at the base of the nodule, leading to the diagnosis of well-differentiated SCC arising from a CHFC. We recommend careful clinical follow-up for patients with relatively large CHFCs as potentially malignant lesions and excision if they show any clinical manifestation

Expression of nm23-H1 gene product in esophageal squamous cell carcinoma and its association with vessel invasion and survival

BACKGROUND: We assessed the nm23-H1 gene product expression and its relationship with lymphatic and blood vessel invasion in patients with esophageal squamous cell carcinoma. METHODS: Formalin-fixed and paraffin-embedded tissue sections from 45 patients who were treated surgically were used in this study. Pathologists graded lymphatic and blood vessel invasion in each of the tissue samples. Expression of nm23-Hl gene product was determined using a specific monoclonal antibody. RESULTS: Expression of nm23-H1 gene product was present in 17 (37.8%) cases. We found an inverse correlation between nm23-H1 gene product expression and lymphatic vessel invasion, whereas no correlation between nm23-H1 gene product expression and blood vessel invasion. Overall survival rate was not different between nm23-H1 gene product positive and negative patients (p = 0.21). However, reduced expression of nm23-H1 gene product was associated with shorter overall survival in patients with involved lymph nodes (p < 0.05), but not in patients without involved lymph nodes (p = 0.87). CONCLUSIONS: In patients with esophageal squamous cell carcinoma, there appears to be an inverse relationship between nm23-H1 gene product expression and lymphatic vessel invasion. Furthermore, nm23-H1 gene product expression might be a prognostic marker in patients with involved lymph nodes. Our data does not demonstrate any correlation between nm23-H1 gene product expression and blood vessel invasion

Human Fibroblast Sheet Promotes Human Pancreatic Islet Survival and Function In Vitro

In previous work, we engineered functional cell sheets using bone marrow-derived mesenchymal stem cells (BM-MSCs) to promote islet graft survival. In the present study, we hypothesized that a cell sheet using dermal fibroblasts could be an alternative to MSCs, and then we aimed to evaluate the effects of this cell sheet on the functional viability of human islets. Fibroblast sheets were fabricated using temperature-responsive culture dishes. Human islets were seeded onto fibroblast sheets. The efficacy of the fibroblast sheets was evaluated by dividing islets into three groups: the islets-alone group, the coculture with fibroblasts group, and the islet culture on fibroblast sheet group. The ultrastructure of the islets cultured on each fibroblast sheet was examined by electron microscopy. The fibroblast sheet expression of fibronectin (as a component of the extracellular matrix) was quantified by Western blotting. After 3 days of culture, islet viabilities were 70.2 ± 9.8%, 87.4 ± 5.8%, and 88.6 ± 4.5%, and survival rates were 60.3 ± 6.8%, 65.3 ± 3.0%, and 75.8 ± 5.6%, respectively. Insulin secretions in response to high-glucose stimulation were 5.1 ± 1.6, 9.4 ± 3.8, and 23.5 ± 12.4 μIU/islet, and interleukin-6 (IL-6) secretions were 3.0 ± 0.7, 5.1 ± 1.2, and 7.3 ± 1.0 ng/day, respectively. Islets were found to incorporate into the fibroblast sheets while maintaining a three-dimensional structure and well-preserved extracellular matrix. The fibroblast sheets exhibited a higher expression of fibronectin compared to fibroblasts alone. In conclusion, human dermal fibroblast sheets fabricated by tissue-engineering techniques could provide an optimal substrate for human islets, as a source of cytokines and extracellular matrix