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

アンゼンナ フククウキョウカ タンノウ テキシュツジュツ ノ タメ ノ ジュツゼン ガゾウ シンダン ノ ヤクワリ

Laparoscopic cholecystectomy becomes one of the standard procedures for digestive surgeons. There is consensus that careful dissection and correct elucidation of the anatomy avoids the complications during cholecystectomy. From May 1991 to March 2005, 433 cases of laparoscopic cholecystectomy were retrospectively analyzed. Conversion to open cholecystectomy was required in 19 cases（4.4%）and the rate of vascular injury or bile duct injury was 0.7% each. CT angiography was effective for preoperative evaluation of vascular anatomy. In many cases, middle hepatic vein was located near gallbladder bed. CT cholangiography was also useful for obtaining information of the biliary tract. Careful evaluation of preoperative CT angiography and cholangiography contributes to decrease the risk of complications during laparoscopic cholecystectomy

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

Nrf2 activation drive macrophages polarization and cancer cell epithelial-mesenchymal transition during interaction

Background: The M2 phenotype of tumor-associated macrophages (TAM) inhibits the anti-tumor inflammation, increases angiogenesis and promotes tumor progression. The transcription factor Nuclear Factor (erythroid-derived 2)-Like 2 (Nrf2) not only modulates the angiogenesis but also plays the anti-inflammatory role through inhibiting pro-inflammatory cytokines expression; however, the role of Nrf2 in the cancer cell and macrophages interaction is not clear. Methods: Hepatocellular carcinoma cells (Hep G2 and Huh 7) and pancreatic cancer cells (SUIT2 and Panc-1) were co-cultured with monocytes cells (THP-1) or peripheral blood monocytes derived macrophages, then the phenotype changes of macrophages and epithelial-mesenchymal transition of cancer cells were detected. Also, the role of Nrf2 in cancer cells and macrophages interaction were investigated. Results: In this study, we found that cancer cells could induce an M2-like macrophage characterized by up-regulation of CD163 and Arg1, and down-regulation of IL-1b and IL-6 through Nrf2 activation. Also, Nrf2 activation of macrophages promoted VEGF expression. The Nrf2 activation of macrophages correlated with the reactive oxygen species induced by cancer cells derived lactate. Cancer cells educated macrophages could activate Nrf2 of the cancer cells, in turn, to increase cancer cells epithelial-mesenchymal transition (EMT) through paracrine VEGF. These findings suggested that Nrf2 played the important role in the cancer cells and macrophages interaction. Conclusions: Macrophage Nrf2 activation by cancer cell-derived lactate skews macrophages polarization towards an M2-like phenotype and educated macrophages activate Nrf2 of the cancer cells to promote EMT of cancer cells. This study provides a new understanding of the role of Nrf2 in the cancer cell and TAM interaction and suggests a potential therapeutic target

Pancreatectomy in patients with HD

Background : Several reports have shown the high mortality rate of pancreatic resection in patients with hemodialysis (HD), however, its long-term outcome remains unclear. In this study, we examined cases of pancreatic resection in patients with HD and conducted a literature review. Methods : Four patients with HD who underwent pancreatic resection from 2004 to 2019 were enrolled. To compare the clinicopathological variables of HD and non-HD patients, 161 non-HD patients who had undergone surgical resection for pancreatic cancer were enrolled. Results : Among four cases of pancreatic resection with HD, three cases were malignant diseases. All patients with HD had some co-morbidities (100% in HD group, 45.3% in the non-HD group) and postoperative complications (100% in the HD group, vs 46.6% in the non-HD group). Although one patient had severe postoperative complications and length of postoperative hospital stay was longer, the 30- and 90-day mortality rates were both 0% in patients with HD. However, three cases in the HD group (75%) died approximately 6 months after surgery, including one cancer-related death. Conclusions : Pancreatic surgery in patients with HD should be carefully indicated, especially pancreaticoduodenectomy or total pancreatectomy, because of the poor prognosis induced by non-cancer-related causes of death

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

セイタイ カンイショク ニオケル カショウ グラフト ノ ビョウタイ セイリ ト チリョウ センリャク

Introduction : To save the small-for-size graft in living donor adult liver transplantation （LDALT）, it is necessary to overcome the following problems：１）excessive portal inflow；２） graft congestion；３）small functional liver mass ; and４）inadequate intragraft responses. Treatments for the small-for-size graft. １）To avoid excessive portal inflow（: a）Splenctomy or splenic artery ligation to reduce portal pressure and flow ; and b）Portocaval shunt to reduce portal pressure and flow. ２）To avoid graft congestion : a）Graft venoplasty and graft hepatic vein to the IVC anastomosis in left lobe grafts, and reconstruction of significant venous tributaries from the middle hepatic vein in right lobe grafts ; and（b）Intraportal administration of drugs（PG-E１, etc.）to prevent microcirculatory disturbance. ３）To avoid liver failure due to small functional liver mass : Hyperbaric oxygen therapy is a feasible option for a persistent functional hyperbiliruminemia. ４）To modulate inadequate intragraft responses（: a）Induction of heat shock protein into the graft to suppress up-regulation of inflammatory cytokines, and to improved survival rate after ９５％-hepatectomy（Hx）in rats ; and（b）Slow-down of liver regeneration to reduce liver injury and to improve survival rate after９０％-Hx in rats. Conclusions : Pathophysiology-oriented strategy against small-for-size graft is effective in LDALT

亜鉛イオン濃度変化は脂肪由来幹細胞から作成するインスリン産生細胞の成熟を反映する

The generation of insulin-producing cells (IPCs) from pluripotent stem cells could be a breakthrough treatment for type 1 diabetes. However, development of new techniques is needed to exclude immature cells for clinical application. Dithizone staining is used to evaluate IPCs by detecting zinc. We hypothesised that zinc ion (Zn2+) dynamics reflect the IPC maturation status. Human adipose-derived stem cells were differentiated into IPCs by our two-step protocol using two-dimensional (2D) or 3D culture. The stimulation indexes of 2D -and 3D-cultured IPCs on day 21 were 1.21 and 3.64 (P < 0.05), respectively. The 3D-cultured IPCs were stained with dithizone during culture, and its intensity calculated by ImageJ reached the peak on day 17 (P < 0.05). Blood glucose levels of streptozotocin-induced diabetic nude mice were normalised (4/4,100%) after transplantation of 96 3D-cultured IPCs. Zn2+ concentration changes in the medium of 3D cultures had a negative value in the early period and a large positive value in the latter period. This study suggests that Zn2+ dynamics based on our observations and staining of zinc transporters have critical roles in the differentiation of IPCs, and that their measurement might be useful to evaluate IPC maturation as a non-destructive method

Intraoperative 3D hologram in liver surgery

An intra-operative 3D hologram with mixed reality techniques contributed to “last-minute simulation”, not for “navigation” in liver surgery. This intra-operative hologram might be a new next-generation operation-supportive tool in terms of spatial awareness, sharing, and simplicity.Objective The aim of this study was to investigate the potential of an intra-operative 3D hologram, which was a computer graphics (CG) model liver, with mixed reality (MR) techniques in liver surgery. Summary Background Data The merits for the application of a hologram for surgical support are: 1) no sterilized display monitor; 2) better spatial awareness; and 3) 3D images shared by all the surgeons. Methods 3D polygon data using pre-operative computed tomography (CT) data was installed into head mount displays, HoloLens (Microsoft Corporation, Redmond, WA). Results In a Wi-Fi-enabled operative room, several surgeons wearing HoloLens succeeded in sharing the same hologram and moving that hologram from respective operators’ angles by means of easy gesture-handling without any monitors. The intra-operative hologram contributed to better imagination of tumor locations, and for determining the parenchymal dissection line in the hepatectomy for the patients with more than twenty (20) multiple colo-rectal liver metastases (CRLMs). In another case, the hologram enabled a safe Gliisonean pedicle approach for hepato-cellular carcinoma (HCC) with a hilar anatomical anomaly. Surgeons could easily compare the real patient’s anatomy and that of the hologram just before the hepatic hilar procedure. Conclusions This initial experience suggested that an intra-operative hologram with MR techniques contributed to “last-minute simulation”, not for “navigation”. The intra-operative hologram might be a new next-generation operation-supportive tool in terms of spatial awareness, sharing, and simplicity