A Case of Pancreatic Ascites and Pleural Effusion: Confirmation of a Pancreatic Duct Contrast Leakage Using Computed Tomography after Endoscopic Retrograde Cholangiopancreatography

A seventy-two year old Japanese man with chronic alcoholism was admitted with increasing epigastric pain and abdominal fullness. He gave a history of bouts of epigastric pain radiating to the back for the past year. At admission, abdominal ultrasonography and computed tomography (CT) demonstrated massive ascites and a pseudocyst in the pancreatic body. A chest X-ray showed bilateral pleural effusion, and the level of amylase was elevated in the serum, urine, ascitic fluid and pleural effusion. First, the patient was treated with nothing by mouth but with intravenous hyperalimentation, however, no improvement was noted after 2 weeks. Then, the patient underwent endoscopic retrograde cholangiopancreatography (ERCP) and abdominal CT after ERCP. They showed irregular dilatation of the pancreatic main duct and branch, and an extravasation of contrast media from the pancreatic duct into the peritoneal cavity, after which the patient underwent surgery. Because no fistula was found during surgery, drainages were retained into the pseudocyst and peritoneal cavity. Due to marked elevation of amylase and protein levels in ascitic fluid and pleural effusion and findings from ERCP and CT after ERCP, pancreatic ascites and pleural effusion was diagnosed. The diagnosis of chronic pancreatitis is due to his history, laboratory data, and irregular dilatation of the pancreatic duct on ERCP. After surgery, his clinical status improved rapidly. We thus described a case of pancreaticoperitoneal fistula demonstrated by CT scan subsequent to ERCP which was treated successfully by surgery

A Case of Ductal Dysplasia of the Pancreas A Possible Prerequisite for Pancreatic Cancer

The precise pathobiology of precursor lesions, which develop into pancreatic adenocarcinoma, remains controversial. Recently, we encountered a patient with dysplastic lesion of the pancreas; a case in which a precursor lesion of the pancreatic carcinoma may have been documented. The patient was a 73-year-old female with epigastric discomfort. As part of a general check-up, she underwent abdominal ultrasound, which revealed the pancreatic duct in the pancreatic body to be slightly indented. Computed tomography (CT) scan revealed mild dilatation of the main pancreatic duct and a small low-density area (less than 1 cm in diameter). Endoscopic retrograde cholangiopancreatography (ERCP) showed the irregularity in the body of the main pancreatic duct. Under general anesthesia, resection of the distal portion of the pancreas was performed with splenic conservation. Pathological examination revealed focal hyperplastic epithelium of the pancreatic duct with moderate dysplasia. Expression of the proliferating cell nuclear antigen (PCNA) in the lesion was observed, indicating a slightly proliferative nature. Mutant p53 protein was slightly expressed in the lesion. As is seen in this case, ductal hyperplasia of the pancreas might represent precursor lesions, and constitute part of a continuous development spectrum evolving into ductal adenocarcinoma of the pancreas with accumulation of genetic alterations

Clinical Significance of Telomerase Activity and Telomere Length in Various Liver Diseases

We investigated the clinical significance of telomerase activity and telomere length in hepatocellular carcinomas (HCCs) and chronic liver diseases. Telomerase activity was assessed quantitatively using \u27Stretch PCR\u27 assay and telomere length by Southern blotting in 24 HCCs, 2 focal nodular hyperplasia, 8 liver cirrhosis, 10 chronic hepatitis and 8 histologically normal livers. The latter were obtained from normal sections of resected specimens of cholangiocellular carcinoma, metastatic liver tumor or hemangioma. The relative titers of telomerase activity (RTA) were significantly higher in HCCs (average, 54 units) than in chronic liver diseases (average, 0.6 units) (P<0.001). In comparison, RTA was less than 2 units in non-malignant liver tissues. Telomere length in cirrhotic liver tissues was significantly shorter than in normal livers and tended to be shorter than those in chronic hepatitis. Telomere length and RTA correlated with the grading of tissue derangement in chronic liver diseases. Our results suggest that RTA estimated by Stretch PCR assay might be clinically useful for accurate diagnosis of liver diseases, particularly HCCs. In addition, telomere length seems to having a possibility as a useful predictor for risk of hepatocarcinogenesis

Underlying Histological Activity of Hepatitis Plays an Important Role for Tumor Recurrence After Curative Resection of Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) commonly develops in patients with chronic hepatitis. This situation is one of the reasons why intrahepatic recurrence frequently occurs even after curative resection. There are two different components of such recurrences, which occurs within 12 months (the early recurrence group) and at more than 12 months after resection (the late recurrence group). The present study was conducted to clarify the factors contributing to these different types of HCC recurrence. Methods: Ninety seven patients who underwent curative resection for HCCs were followed for initial recurrence, and predictive factors of recurrence were examined. Results: Early and late intrahepatic recurrences developed in 30 and 42 patients, respectively. In the former group, univariate analyses showed the serum AFP level (>100ng/ml, P=0.045), higher inflammatory activity (Grading) (p=0.048) and status of fibrosis (Staging) (p=0.027) in non-cancerous liver tissues to be significant risk factors, while the serum AFP level (>100ng/ml) was the only independent risk factor based on a multivariate analysis (RR: 2.78). In the latter group, only the presence of hyperplastic foci (HPF) was found to be a significant risk factor (p=0.005). Higher Grading tended to be linked to shorter disease-free survival time, although not significant. In the non-cancerous liver tissues with HPF, the level of Grading, Staging, and PCNA labeling index was significantly higher (p=0.033, 0.003, 0.040, respectively).Conclusion: Not only the tumor factors but also the underlying hepatic status including HPF, Grading, and Staging were significant risk factors for intrahepatic recurrence after curative resection for HCC

Low-dose recombinant human hepatocyte growth factor enhances effect of hepatocyte transplantation in rats treated with retrorsine.

BACKGROUND/AIMS: The aim of this study was to regenerate transplanted hepatocytes selectively in a recipient using retrorsine and recombinant human hepatocyte growth factor (rhHGF). METHODOLOGY: Nagase analbuminemic rats (NARs) received pretreatment with retrosine and were divided into three experimental groups. Group1: Hepatocyte transplantation (HcTx) + 50 microg/kg/day rhHGF. Group2: HcTx + 250 microg/kg/day rhHGF. Group3: HcTx + normal saline. The serum levels of albumin and the albumin-positive hepatocytes in the liver were investigated. The rat endogenous HGF of the rats given only retrorsine was measured. RESULTS: The serum albumin levels of Group11 were higher than those of Group2, while there was no significant difference between Group2 and GroupS. Histological examination of Group1 and 3 showed the presence of a large number of albumin-positive hepatocytes, which frequently consisted of large clusters and occupied 53.90 +/- 2.31% and 31.25 +/- 5.36% of host liver, respectively. The liver sections of Group2 showed numerous albumin-positive hepatocyte, which were not seen as clusters. The rat endogenous HGF concentration was extremely high. CONCLUSION: Low-dose rhHGF enhances the effect of HcTx under the suppressive state of proliferation of host hepatocytes. Because of the high endogenous HGF, the administration of a high concentration of rhHGF suppressed the regenerative activity of the transplanted hepatocytes

The expression of transporter OATP2/OATP8 decreases in undetectable hepatocellular carcinoma by Gd-EOB-MRI in the explanted cirrhotic liver

Purpose: The aim of this study is to evaluate the detectability of hepatocellular carcinoma (HCC) in the explanted cirrhotic liver using gadoxetic acid-enhanced magnetic resonance imaging (Gd-EOB-MRI) and the degree of organic anion transporter OATP2/OATP8 (OATP1B1/1B3) HCC which could not be preoperatively detected by multi-detector computed tomography (MD-CT) and Gd-EOB-MRI. Methods: Eleven patients (HBV 3, HCV 7, nonBnonC 1) out of 145 recipients of liver transplantation were analyzed. The detectability by each imaging modality and the expression of OATP2/OATP8 of HCC were analyzed using the whole liver thin sliced histological and immunohistochemical examination retrospectively. Results: The imaging examination detected 17 lesions of HCC by MDCT and/or Gd-EOB-MRI. Only one lesion detected by Gd-EOB-MRI had well differentiated and minute (7 mm) HCC. However, the histological examination revealed newly 11 lesions and one false-positive lesion of HCC in the explanted livers. The median diameter of the preoperatively undetectable HCC by imaging was 8 mm (2-12). The histological characteristic of the preoperatively undetectable HCC was well differentiated HCC (10/11). The accuracy rate in MDCT and Gd-EOB-MRI was 53.6 % (15/28) and 57.1 % (16/28). The rate of positive predictive value in MDCT and Gd-EOB-MRI was 93.7 % (15/16) and 94.2 % (16/17), respectively. The expression of OATP2/OATP8 in the preoperatively undetectable HCC was negative in nine lesions, was weak positive in two lesions. Conclusions: The detectability of Gd-EOB-MRI is almost equal to MDCT in a cirrhotic liver. Small HCCs were difficult to detect even with Gd-EOB-MRI. The transporter of OATP2/OATP8 was less expressed in the preoperatively undetectable HCCs

Acute deterioration of idiopathic portal hypertension requiring living donor liver transplantation: a case report.

Case reports of severe idiopathic portal hypertension (IPH) requiring liver transplantation are very rare. We report the case of a 65-year-old woman who was diagnosed as having IPH. At the age of 60 years, her initial symptom was hematemesis, due to ruptured esophageal varices. Computed tomography of the abdomen showed splenomegaly and a small amount of ascites, without liver cirrhosis. She was diagnosed as having IPH and followed-up as an outpatient. Five years later, she developed symptoms of a common cold and rapidly progressive abdominal distension. She was found to have severe liver atrophy, liver dysfunction, and massive ascites. Living donor liver transplantation was then performed, and her postoperative course was uneventful. Histopathological findings of the explanted liver showed collapse and stenosis of the peripheral portal vein. The areas of liver parenchyma were narrow, while the portal tracts and central veins were approximate one another, leading to a diagnosis of IPH. There was no liver cirrhosis. The natural history of refractory IPH could be observed in this case. Patients with end-stage liver failure due to severe IPH can be treated by liver transplantation

Actual therapeutic efficacy of pre-transplant treatment on hepatocellular carcinoma and its impact on survival after salvage living donor liver transplantation.

BACKGROUND: The exact efficacy of pre-liver transplant (LT) therapy for hepatocellular carcinoma (HCC) and the impact on survival after LT remain controversial in regard to salvage LT. MATERIALS AND METHODS: Of 79 patients transplanted in Nagasaki University Hospital between August 1997 and December 2007, 29 patients (36.7%) were indicated for HCC based on the Milan criteria using computed tomography and magnetic resonance imaging. Pre-LT therapy other than liver resection had been performed in 18 cases (62.1%) for 24 lesions. Treated lesions were analyzed histologically using thin slices of the whole explanted liver. RESULTS: Pre-LT therapy included transarterial chemoembolization (TACE) for 10 lesions, percutaneous ethanol injection (PEI) + TACE for 1 lesion, PEI in 6 lesions and ablation therapy in 7 lesions. Under preoperative imaging study, 19 lesions (79.1%) were "thought-to-be" necrotic by pre-LT therapy. However, histologically, viable HCCs were still observed in 9 lesions (9/19 47%). A median interval between the first pre-therapy and LT was 22 months, while last pre-LT therapy and LT was 11 months. No sarcomatous HCC or forced portal venous tumor thrombus was found in all cases with residual lesions. One peritoneal recurrence has occurred after LT, in whom PEI and RFA had been performed before LDLT. The disease free survival after LDLT was comparable to that of cases without pre-LT therapy. CONCLUSION: Half of the preoperatively "thought-to-be" necrotic lesions still contained viable HCC cells after the pre-LT treatment. Overall, the history of pre-LT therapy does not preclude or interfere with subsequent LT, although percutaneous treatment may spread disseminated tumor cell growth under immunosuppression

Two-staged living donor liver transplantation for fulminant hepatic failure

We reported a first successful and life-saving two-staged living-related liver transplantation for a patient with imminent brain death due to fulminant hepatic failure that otherwise had to be performed after a pre-treated and scheduled blood-type incompatible liver transplantation. The patient was anhepatic for 6 hr 34 min, and continuous hemodiafiltration was given throughout the operation. The patient recovered quickly and was extubated within 24 hr after transplant. This two-staged procedure is useful for emergency living-related liver transplantation that needs to be performed when the operating room is busy with other emergency or scheduled surgical procedures, and may allow clearance of toxic metabolites during the anhepatic period