Significance of portal venous VEGF during liver regeneration after hepatectomy.

BACKGROUND: Although some studies have hypothesized portal venous blood is important for liver regeneration, no studies have established organs whose venous effluent flow into the portal vein secrete liver regenerating factors into the portal vein during liver regeneration. The aim of this study was to elucidate up-regulation of vascular endothelial growth factor (VEGF) in the portal vein, and expressions of hepatic regenerating factors in organs whose venous effluent flows into the portal vein during liver regeneration. MATERIALS AND METHODS: VEGF protein in systemic and portal venous blood, as well as expression of VEGF, hypoxia-inducible factor-1alfa (HIF-1alpha), hepatocyte growth factor (HGF), and HGF activator (HGFA) mRNA were evaluated in the regenerating liver, spleen, and intestine following 70% partial hepatectomy (PHx) in rats. RESULTS: The portal VEGF protein level was significantly higher than the systemic level post-PHx (portal/systemic at 72, 120, and 168 h post-PHx: 17.2/13.0, 20.2/12.8, and 24.0/14.7 pg/mL; P = 0.003, P = 0.022 and P = 0.032, respectively). VEGF mRNA expressions were significantly higher in the liver (P = 0.000027: 168 h), spleen (P = 0.000059: 72 h) and intestine (P = 0.01: 24-72 h) post-PHx compared with pre-PHx. HIF-1alpha, HGF, and HGFA mRNA expressions in the liver, intestine, and spleen were also significantly higher post-PHx compared to pre-PHx. CONCLUSIONS: Portal VEGF was significantly higher than systemic VEGF, and expressions of VEGF, HIF-1alpha, HGF, and HGFA mRNA in the liver, spleen and intestine were also up-regulated during liver regeneration. These results suggest that hepatic regenerating factors derived from the spleen or intestine may contribute liver regeneration

C-arm Cone-beam CT-guided Needle Biopsies through the Erector Spinal Muscle for Posterior Thoracic Pulmonary Lesions

This study investigated retrospectively the diagnostic yield and complication rate of transthoracic needle biopsies for posterior thoracic pulmonary lesions using C-arm cone-beam computed tomography （CBCT）. The risk factors for pulmonary hemorrhage were evaluated. Our study included 113 patients with 113 posterior pulmonary lesions （mean longest diameter: 30.6mm, and mean depth: 4.7mm） through the erector spinal muscles using a 19/20-gauge coaxial system. The diagnostic performances of procedures for malignant lesions and the incidence of complications after biopsies were also assessed. The patient-related and procedure-related variables were investigated. Risk factors for pulmonary hemorrhage were analyzed with a multivariate logistic regression analysis. Findings revealed 99 malignant, 13 benign, and one intermediate lesion. Sensitivity, specificity, and diagnostic accuracy rates were 100％ （99/99）, 92.3％ （12/13）, and 99.1％ （111/112）, respectively. Air embolization, hemothorax, hemoptysis, pneumothorax, and pulmonary hemorrhage, occurred in 0, 2, 12, 48, and 70 procedures. The averaged spinous process-pleura depth and the traversed lung parenchyma depth achieved by the introducer needles were 54.2mm and 27.4mm, respectively. The needle position at the pleural puncture site within the intercostal space was in middle （31％） and inferior （69％） areas. The incidence of pulmonary hemorrhage was significantly higher in smaller lesions （p＝0.001）. Manual evacuation was performed in five procedures for patients with pneumothorax. The chest tube placement （trocar＞8 Fr） was performed in two procedures in patients with hemothorax and pneumothorax. In conclusion, the biopsy method with a posterior intercostal approach for posterior thoracic pulmonary lesions yielded high diagnostic accuracy and few major complications

Comprehensive and innovative techniques for laparoscopic choledocholithotomy: A surgical guide to successfully accomplish this advanced manipulation

Surgeries for benign diseases of the extrahepatic bile duct (EHBD) are classified as lithotomy (i.e., choledocholithotomy) or diversion (i.e., choledochojejunostomy). Because of technical challenges, laparoscopic approaches for these surgeries have not gained worldwide popularity. The right upper quadrant of the abdomen is advantageous for laparoscopic procedures, and laparoscopic choledochojejunostomy is safe and feasible. Herein, we summarize tips and pitfalls in the actual procedures of choledocholithotomy. Laparoscopic choledocholithotomy with primary closure of the transductal incision and transcystic C-tube drainage has excellent clinical outcomes; however, emergent biliary drainage without endoscopic sphincterotomy and preoperative removal of anesthetic risk factors are required. Elastic suture should never be ligated directly on the cystic duct. Interrupted suture placement is the first choice for hemostasis near the EHBD. To prevent progressive laceration of the EHBD, full-layer interrupted sutures are placed at the upper and lower edges of the transductal incision. Cholangioscopy has only two-way operation; using dedicated forceps to atraumatically grasp the cholangioscope is important for smart maneuvering. The duration of intraoperative stone clearance accounts for most of the operative time. Moreover, dedicated forceps are an important instrument for atraumatic grasping of the cholangioscope. Damage to the cholangioscope requires expensive repair. Laparoscopic approach for choledocholithotomy involves technical difficulties. I hope this document with the visual explanation and literature review will be informative for skillful surgeons

Living-donor liver transplantation for moderate or severe porto-pulmonary hypertension accompanied by pulmonary arterial hypertension: a single-centre experience over 2 decades in Japan.

[Background]Candidates for orthotopic liver transplantation (OLT) often have porto-pulmonary hypertension (PPHTN) with pulmonary arterial hypertension (PAH). Poor outcomes of PPHTN contraindicate OLT. There are no guidelines for living-donor liver transplantation (LDLT) in PPHTN patients. [Methods]We present our experiences of LDLT in six patients with moderate or severe PPHTN, along with our institutional guidelines. Three had liver cirrhosis and three were non-cirrhotic. Catheterization studies were undertaken before, during and after LDLT, and the mean pulmonary arterial pressure (mPAP), cardiac output (CO), pulmonary vascular resistance and total peripheral resistance (TPR) were monitored. [Results]The results showed significant differences in CO and TPR between cirrhotic and non-cirrhotic patients before, during and after LDLT. Cirrhotic patients showed systemic hyperdynamic state. Two cirrhotic patients showed poor responses to pre-transplant treatment, and continued to have increased PAH and poor clinical courses after LDLT. LDLT has an advantage of flexible timing of LT. Currently in our institution, PPHTN patients with mPAP <40 mmHg are registered for LDLT after treatment and catheterization. However, LDLT is performed when mPAP is ≤35 mmHg, leading to improved outcomes. [Conclusion]PPHTN patients with well-controlled PAH, or secondary PAH resulting from porto-systemic shunts, may be appropriate candidates for LDLT after careful considerations