カンフゼン ニ タイスル ゲカテキ アプローチ : トクシマ デノ セイタイ カンイショク ノ シンチョク ト セカイ エノ ハッシン ノ タメ ノ アラタナ センリャク

I herein introduce a new surgical strategy against liver failure, which includes liver transplantation（especially living donor liver transplantation（LDLT））, splenectomy and artificial liver support system. I wan to emphasize progress of LDLT in Tokushima. Since restart of LDLT in February 2005, five consecutive cases have been done thanks to all staffs in Tokushima University Hospital. Surgical technique of LDLT is excellent, judging from intraoperative blood loss of both donors and recipients. Overall survival rate（80%）is satisfactory. In Japan, only 31 cases underwent liver transplantation from deceased（=brain-dead）donor since February 1999（below 5 cases per year）. This number is unbelievable when compared to USA（over 4,500 cases per year）. Under such abnormal circumstances, there are many patients with end-stage liver disease who can not under go LDLT due to no donor. Splenectomy is a promising modality for those patients, which brings improvement of hypersplenism（low platelet count and leukocyte count） liver function tests（bilirubin value and ICGR-15）,and nutritional state. Furthermore, liver regeneration is suggested to be promoted. Our new type of artificial liver support system using a photocatalystic effect of titanium is also a next-generation therapy for liver failure. In conclusions, a top-level LDLT became possible in Tokushima, however, increase in number of liver transplantation from deceased donor is a big and urgent problem. Splenectomy may be one of the most important modalities for liver-failured patients without any living donor. I am going to create original and high-quality therapeutic methods for liver failure as many as possible in order to send new information to all over the world as a center of liver-failure management institutions in Shikoku Island. Again, I appreciate all staffs in TheTokushima University Hospital regarding success in restart of LDLT

肝胆膵手術の画像支援

We introduced the pre and intra-operative３D hologram support system, which was a computer graphics model, with extended reality（XR）techniques. It contributed to a more extensive view of ３D anatomy from various angles and the sharing of the same hologram from several respective operators’ angles. The colabolation between such an operative supporrt and pathological diagnosis enables more safe and higher quality operations

Update on perioperative management of patients undergoing surgery for liver cancer

Hepatocellular carcinoma is often accompanied by chronic hepatitis or cirrhosis. Preoperative evaluation of liver function and postoperative nutritional management are critical in patients with hepatocellular carcinoma who undergo liver surgery. Although the incidence of postoperative complications and death has declined in Japan over the last 10 years, postoperative complications have not been fully overcome. Therefore, surgical procedures and perioperative management must be improved. Accurate preoperative evaluations of liver function, nutrition, inflammation, and body skeletal muscle are required. Determination of the optimal surgical procedure should consider not only tumor characteristics but also the physical reserve of the patient. Nutritional management of chronic liver disorders, especially maintaining protein synthesis for postoperative protein/energy, is important. Prophylactic antibiotics are recommended for short-term use within 24 hours after surgery. Abdominal drainage is recommended for patients with cirrhosis who may develop large amounts of ascites, who are at risk of postoperative bleeding, or who may have bile leakage due to a large resection area. Postoperative exercise therapy may improve insulin resistance in patients with chronic liver damage. Implementation of an early/enhanced recovery after surgery program is recommended to reduce biological invasive responses and achieve early independence of physical activity and nutrition intake. We review the latest information on the perioperative management of patients undergoing liver resection for hepatocellular carcinoma

Essential updates 2020/2021 : Current topics of simulation and navigation in hepatectomy

With the development of three-dimensional (3D) simulation software, preoperative simulation technology is almost completely established. The remaining issue is how to recognize anatomy three-dimensionally. Extended reality is a newly developed technology with several merits for surgical application: no requirement for a sterilized display monitor, better spatial awareness, and the ability to share 3D images among all surgeons. Various technology or devices for intraoperative navigation have also been developed to support the safety and certainty of liver surgery. Consensus recommendations regarding indocyanine green fluorescence were determined in 2021. Extended reality has also been applied to intraoperative navigation, and artificial intelligence (AI) is one of the topics of real-time navigation. AI might overcome the problem of liver deformity with automatic registration. Including the issues described above, this article focuses on recent advances in simulation and navigation in liver surgery from 2020 to 2021

Regeneration of caudate lobe in left lobe graft

Background : The aim of this study is to clarify the regeneration of the CL (caudate lobe) without any reconstructions of short hepatic veins (SHVr) after LDLT (living donor liver transplantation) and compare the regeneration of the CL after right hepatectomy (Rt. Hx), as the surrogate model of extended left lobe graft (Ex LLG) with complete SHVr. Methods : Eleven Ex LLGs with CL were included in this study. SHVr was not performed in all cases. The volumetry was performed before, one month and six months after LDLT. Seven patients who underwent Rt. Hx were also included in this study as the surrogate model. Results : In Ex LLGs with CL, the regeneration rate of the large CL (> 30 ml) was worse than that of small CL (< 30 ml). In the surrogate model, the regeneration rate of the CL was not worse than other segments. However, the regeneration rate of the large CL was also worse than that of small CL even in the presence of complete SHVr. Conclusions : The regeneration of the large CL was worse than that of the small CL regardless of the presence or absence of SHVr, indicating that SHVr in Ex LLG with CL might not be necessary

Major liver resection reduces nonprotein respiratory quotient and increases nonesterified fatty acid at postoperative day 14 in patients with hepatocellular carcinoma

Background & aims: We reported decreased nonprotein respiratory quotient (npRQ) after liver resection in patients with hepatocellular carcinoma (HCC); however, whether liver resection volume affects energy metabolism in these patients is unclear. We aimed to examine the relationship between liver resection and energy metabolism indices. Methods: NpRQ was measured in 53 patients with HCC and seven with at the pre- and postoperative days. Patients were classified into four groups: Minor-lowICG group (n = 17): minor (subsegment or less) resection and low indocyanine green retention rate at 15 min (ICGR15) (<15%); Minor-highICG group (n = 18): minor resection and high ICGR15 (≥15%) and Major-lowICG group (n = 18): major (lobe) resection and low ICGR15 (<15%). We investigated dietary intake and blood biochemistry at energy measurement. The difference in npRQ and nonesterified fatty acid (NEFA) pre- and post-hepatectomy was shown as ΔnpRQ and ΔNEFA, respectively. Results: Compared with the preoperative values, npRQ significantly decreased in the Minor-highICG and Major-lowICG groups and NEFA significantly increased in the Major-lowICG group at postoperative day 14. In single regression analysis, ΔnpRQ significantly correlated with HCV infection and ΔNEFA with resection volume, HCV infection, and ICGR15. In multiple regression analysis, ΔNEFA significantly correlated with resection volume after adjusting for age, etiology, and ICGR15. Conclusions: These results suggest that postoperative nutritional recovery is slower in major resection than in minor resection patients. Hence, nutritional care to prevent starvation is needed in major resection patients

脂肪由来間葉系幹細胞からインスリン産生細胞への分化誘導に際しての皮下および腹腔内脂肪の特性の差異に関する研究

The aim of this study was to investigate the characteristics of insulin producing cells (IPCs) differentiated from adipose-tissue derived stem cells (ADSCs) isolated from human subcutaneous and visceral adipose tissues and identify ADSCs suitable for differentiation into efficient and functional IPCs. Subcutaneous and visceral adipose tissues collected from four (4) patients who underwent digestive surgeries at The Tokushima University (000035546) were included in this study. The insulin secretion of the generated IPCs was investigated using surface markers by: fluorescence activated cell sorting (FACS) analysis; cytokine release; proliferation ability of ADSCs; in vitro (glucose-stimulated insulin secretion: (GSIS) test/in vivo (transplantation into streptozotocin-induced diabetic nude mice). The less fat-related inflammatory cytokines secretions were observed (P < 0.05), and the proliferation ability was higher in the subcutaneous ADSCs (P < 0.05). Insulin expression and GISI were higher in the subcutaneous IPCs (P < 0.01 and P < 0.05, respectively). The hyperglycaemic state of all mice that received IPCs from subcutaneous fat tissue converted into normo-glycaemia in thirty (30) days post-transplantation (4/4,100%). Transplanted IPCs were stained using anti-insulin and anti-human leukocyte antigen antibodies. The IPCs generated from the ADSCs freshly isolated from the human fat tissue had sufficient insulin secreting ability in vitro and in vivo