Akira Nii

Current Concept of Small-for-Size Grafts in Living Donor Liver Transplantation

The extended application of living donor liver transplantation (LDLT) has revealed the problem of graft size mismatching called “small-for-size (SFS) graft syndrome.” The initial trials to resolve this problem involved increasing the procured graft size, from left to right, and even extension to include a right lobe graft. Clinical cases of living right lobe donations have been reported since then, drawing attention to the risks of increasing the liver volume procured from a living donor. However, not only other modes of increasing graft volume such as auxiliary or dual liver transplantation, but also control of the increased portal pressure caused by an SFS graft, such as a portosystemic shunt or splenectomy, have been trialed with some positive results. To establish an effective strategy for transplanting SFS grafts and preventing SFS graft syndrome, it is essential to have precise knowledge and tactics to evaluate graft quality and graft volume, when performing these LDLTs with portal pressure control. We reviewed the updated literature on the pathogenesis of and strategies for using SFS grafts.

Real time elastography for noninvasive diagnosis of liver fibrosis

BACKGROUND/PURPOSE The accurate preoperative evaluation of liver fibrosis stage is important in determining surgical procedures. Although percutaneous liver biopsy is the gold standard, it may cause undesirable complications, such as bleeding. This study aimed to evaluate the usefulness of real-time tissue elastography for the preoperative assessment of liver fibrosis stage. METHODS We focused on a new mode of sonogram, real-time elastography, which can show tissue elasticity on images, and express the elasticity numerically. The elastic ratio of the liver for the intercostal muscle for each patient was calculated preoperatively, using the sonography device. The liver fibrosis stages were finally determined in the operative specimens from 41 patients. We examined the correlation between the elastic ratio and the histological fibrosis stage. RESULTS The lower the elastic ratio, the more advanced was the liver fibrosis stage. There was a significant correlation between the elastic ratio and the histological fibrosis stage. The area under the receiver-operating characteristics curve for the diagnosis of significant liver fibrosis using this device was superior to those conventionally determined by blood parameters. CONCLUSIONS Real-time elastography is a promising sonography-based noninvasive method for the preoperative assessment of liver fibrosis.

Efficacy of vessel sealing system for major Glisson bundles and major bile ducts

BACKGROUND/PURPOSE The efficacies of vessel sealing system (VSS) devices for major Glisson bundles and major bile ducts have not yet been determined. METHODS Male pigs (n = 6) and a LigaSure V device and an Atlas 20 (Valleylab, Boulder, CO, USA) device were used in this study. After laparotomy, the common bile duct and the right and left first-degree Glisson bundles were sealed by the VSS. The lower and upper parts of the common bile ducts were also sealed. Macro-and microscopic examinations were performed for the analysis of specimens taken just after VSS application. In an analysis of bile duct specimens taken 1 week after the VSS application, both burst pressure tests and histological examinations were performed. RESULTS (1) In the analysis of the specimens (Glisson bundles and bile ducts) obtained just after the VSS application, the macroscopic changes included permanent, flattened changes of the Glisson bundles and bile ducts, without showing any blood or bile leakage. Histological examination of the transverse sections of the Glisson bundle after VSS application revealed that not only the blood vessels but also the bile ducts were fused together. (2) In the analysis of the specimens (bile ducts) obtained 1 week after the VSS application, second-look laparotomy showed extrahepatic bile duct obstruction. The mean burst pressure of the sealed bile ducts was 74.4 +/- 20.1 mmHg. Histological examination revealed that the lumen of the bile duct was completely sealed and the duct was surrounded by dense connective tissues. CONCLUSIONS The VSS is useful for the safe sealing of not only the major Glisson bundles but also the major bile ducts.

Significance of dihydropyrimidine dehydrogenase and thymidylate synthase mRNA expressions in hepatocellular carcinoma

Aim:  The significance of dihydropyrimidine dehydrogenase (DPD) and thymidylate synthase (TS) gene expressions for the post‐surgical prognosis of hepatocellular carcinoma (HCC) has not yet been determined. In the present study, we clarified the significance of DPD and TS gene expressions for the prognosis of HCC.

Ganglioneuroblastoma, intermixed with opsoclonus-myoclonus syndrome

Opsoclonus–myoclonus syndrome (OMS), also called ‘opsoclonus polymyoclonia syndrome’ or ‘dancing eyes syndrome’, is a rare condition characterized by rapid, involuntary, irregular movement of the eyeballs, myoclonus of the limbs and body trunk, and symptoms of cerebellar ataxia. The majority of OMS cases have neuroblastoma as a complication, while OMS is seen in only 2–3% of patients with neuroblastoma. In addition, in children, OMS is rarely seen as paraneoplastic syndrome. Infections are also seen in a small number of patients. The prognosis of patients with OMS complicated by neuroblastoma is generally said to be good, although the neurological prognosis is compromised. Neurological sequelae are said to include residual symptoms involving motor, language, and cognitive functions in 70–80% of patients with OMS. Steroids, corticotropin, immunosuppressants, Rituximab, and gammaglobulin are often used to treat those symptoms, but a standard therapeutic approach has not yet been established for OMS.

A rare case of inguinal bladder hernia in a child

Indirect inguinal hernia requiring surgical treatment is common in children and most patients recover uneventfully. However, rare complications, such as bladder damage, have been reported. Here, we report a rare case of pediatric bladder hernia presenting as an incarcerated inguinal hernia. In the laparoscopic inspection of this case, we were unable to identify patent processus vaginalis but found the bladder protrusion during an inguinal incision approach. Similar cases carry a risk of intraoperative bladder injury.