Atsushi Sugioka

Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka.

OBJECTIVE This review aims to assess the impact of implementing dedicated emergency surgical services, in particular acute care surgery, on clinical outcomes. BACKGROUND The optimal model for delivering high-quality emergency surgical care remains unknown. Acute Care Surgery (ACS) is a health care model combining emergency general surgery, trauma, and critical care. It has been adopted across the United States in the management of surgical emergencies. METHOD A systematic review was performed after PRISMA recommendations using the MEDLINE, Embase, and Psych-Info databases. Studies assessing different care models and institutional factors affecting the delivery of emergency general surgery were included. RESULTS Twenty-seven studies comprising 744,238 patients were included in this review. In studies comparing ACS with traditional practice, mortality and morbidity were improved. Moreover, time to senior review, delays to operating theater, and financial expenditure were often reduced. The elements of ACS models varied but included senior clinicians present onsite during office hours and dedicated to emergency care while on-call. Referrals were made to specialist centers with primary surgical assessments taking place on surgical admissions units rather than in the emergency department. Twenty-four-hour access to dedicated emergency operating rooms was also described. CONCLUSIONS ACS models as well as centralized units and hospitals with dedicated emergency operating rooms, access to radiology and intensive care facilities (ITU) are all factors associated with improved clinical and financial outcomes in the delivery of emergency general surgery. There is, however, no consensus on the elements that constitute an ideal ACS model and how it can be implemented into current surgical practice.

Laparoscopic total gastrectomy with distal pancreatosplenectomy and D2 lymphadenectomy for advanced gastric cancer

The standard lymph node dissection for advanced gastric cancer is a D2 dissection. Although D2 laparoscopy-assisted total gastrectomy with distal pancreatosplenectomy has been reported, no studies have reported a completely intra-abdominal laparoscopic approach, because of the technical difficulty of the procedure. We successfully performed this novel procedure in two patients with advanced gastric cancer located in the upper portion of the stomach. In fact, this surgery is technically feasible, and has a potential curability comparable with that of open surgery.

Completely laparoscopic extraperigastric lymph node dissection for gastric malignancies located in the middle or lower third of the stomach

Abstract:Dissection of the extraperigastric lymph nodes is necessary in most submucosal gastric cancers. Laparoscopy-assisted gastrectomy with extraperigastric lymph node dissection via minilaparotomy has been performed, but, to our knowledge, completely laparoscopic extraperigastric lymph node dissection has never been reported. We successfully performed completely laparoscopic distal gastrectomy with extraperigastric lymph node dissection in 12 patients, of whom 11 had early gastric cancer and 1 had malignant lymphoma. This surgery is technically feasible, has an acceptable complication rate, and a curability similar to that with open surgery.

A common polymorphism in the interleukin 8 gene promoter is associated with Clostridium difficile diarrhea.

In mouse liver transplantation, tolerance is readily inducible. Recent studies have revealed that CD25+CD4+ regulatory T cells play an important role in regulating various immune responses, including transplant tolerance. However, the contribution of these cells to tolerance in mouse liver transplantation has not been elucidated. We showed here that depletion of CD25+CD4+ T cells increased proliferative response of CD4+ T cells and cytotoxic T lymphocyte induction of CD8+ T cells. Depletion of these cells in the recipient but not in the donor before liver transplantation caused rejection. Furthermore, the number of CD25+CD4+ population and forkhead/winged helix transcription factor expression in liver mononuclear lymphocytes derived from tolerant mice were higher than those from grafts undergoing rejection. In conclusion, these results indicate that CD25+CD4+ regulatory T cells in the recipient but not in the donor of liver transplantation are important for the tolerance induction. Liver Transpl 12:1112–1118, 2006.

Laparoscopic D2 lymph node dissection for advanced gastric cancer located in the middle or lower third portion of the stomach.

Abstract The standard lymph node dissection for advanced gastric cancer is a D2 dissection, performed in accordance with the new Japanese classification of gastric carcinoma (13th edition). Although laparoscopic D2 dissections according to the General rules for gastric cancer study (12th edition) have been reported, no studies have reported laparoscopic D2 dissections according to the revised classification for advanced gastric cancers located in the middle or lower portions of the stomach. The lack of such studies is due to the perceived technical difficulty of the procedure. However, we successfully performed this novel procedure in five patients with advanced gastric cancer located in the middle or lower portions of the stomach. In fact, this surgical procedure is technically feasible and safe.

Long-term and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching: A multi-institutional Japanese study

The aim of this study was to compare the long‐term outcomes and perioperative outcomes of laparoscopic liver resection (LLR) with those of open liver resection (OLR) for hepatocellular carcinoma (HCC) between well‐matched patient groups.

PD-1/B7-H1 interaction contribute to the spontaneous acceptance of mouse liver allograft.

The programmed death‐1 (PD‐1)/B7‐H1 pathway acts as an important negative regulator of immune responses. We herein investigated the role of the PD‐1/B7‐H1 pathway in establishing an immunological spontaneous tolerance status in mouse liver allografting. B7‐H1 is highly expressed on the donor‐derived tissue cells and it is also associated with the apoptosis of infiltrating T cells in the allografts. Strikingly, a blockade of the PD‐1/B7‐H1 pathway via anti‐B7‐H1mAb or using B7‐H1 knockout mice as a donor led to severe cell infiltration as well as hemorrhaging and necrosis, thus resulting in mortality within 12 days. Furthermore, the expression of the FasL, perforin, granzyme B, iNOS and OPN mRNA in the liver allografts increased in the antibody‐treated group in comparison to the controls. Taken together, these data revealed that the B7‐H1 upregulation on the tissue cells of liver allografts thus plays an important role in the apoptosis of infiltrating cells, which might play a critical role of the induction of the spontaneous tolerance after hepatic transplantation in mice.

Comprehensive screening for antigens overexpressed on carcinomas via isolation of human mAbs that may be therapeutic

Although several murine mAbs that have been humanized became useful therapeutic agents against a few malignancies, therapeutic Abs are not yet available for the majority of the human cancers because of our lack of knowledge of which antigens (Ags) can become useful targets. In the present study we established a procedure for comprehensive identification of such Ags through the extensive isolation of human mAbs that may become therapeutic. Using the phage-display Ab library we isolated a large number of human mAbs that bind to the surface of tumor cells. They were individually screened by immunostaining, and clones that preferentially and strongly stained the malignant cells were chosen. The Ags recognized by those clones were isolated by immunoprecipitation and identified by MS. We isolated 2,114 mAbs with unique sequences and identified 21 distinct Ags highly expressed on several carcinomas. Of those 2,114 mAbs 356 bound specifically to one of the 21 Ags. After preparing complete IgG1 Abs the in vitro assay for Ab-dependent cell-mediated cytotoxicity (ADCC) and the in vivo assay in cancer-bearing athymic mice were performed to examine antitumor activity. The mAbs converted to IgG1 revealed effective ADCC as well as antitumor activity in vivo. Because half of the 21 Ags showed distinct tumor-specific expression pattern and the mAbs isolated showed various characteristics with strong affinity to the Ag, it is likely that some of the Ags detected will become useful targets for the corresponding carcinoma therapy and that several mAbs will become therapeutic agents.

Participation of autophagy in the initiation of graft dysfunction after rat liver transplantation

Better ways to prevent the cold ischemia-warm reperfusion (CI/WR) injury associated with liver transplantation are needed, and many investigations have focused on the molecular mechanisms of this injury. However, the mechanisms reported to date are controversial and no improvement in therapy has resulted. Here, using prolonged CI and orthotopic transplantation of rat liver grafts, we found that the CI/WR injury was closely associated with autophagy. By 15 min after the start of WR, small masses of hepatocytes that possessed abundant autophagosomes and autolysosomes frequently dissociated from the hepatic cords and obstructed the sinusoid, causing massive necrosis of hepatocytes within 2 hours. The cell masses included TUNEL-positive nuclei without caspase-3 and -7 activation. Autophagy suppression with the phosphatidylinositol 3-kinase (PI3K) inhibitors, wortmannin or LY294002, reduced both liver damage and the mortality rate of recipient rats. To elucidate the downstream mechanisms of this autophagic pathway, liver grafts were treated with aspartic and cysteine proteinase inhibitors, pepstatin and leupeptin. This treatment also significantly improved the survival rate of recipient rats. These data suggest that autophagy-associated hepatocyte death triggers liver graft dysfunction. The protective effects of suppressing autophagy may suggest new ways to prevent CI/WR injury of the liver.

Completely laparoscopic proximal gastrectomy with jejunal interposition and lymphadenectomy1

Proximal gastrectomy with gastroesophagostomy or jejunal interposition is being performed widely in Japan for early-stage gastric neoplasm in the upper portion of the stomach. Its frequent use is partially attributable to the improved postoperative fat absorption, nutrition, and release of gut hormones associated with the procedure as compared with total gastrectomy. Whether gastroesophagostomy or jejunal interposition should be selectively performed after proximal gastrectomy is a controversial matter of opinion. Although gastroesophagostomy is a simple, easy, and safe procedure, it results in a high incidence of reflux esophagitis. In this respect, jejunal or jejunal pouch interposition is superior to gastroesophagostomy as a followup procedure to proximal gastrectomy. Recently, to achieve less invasive surgery, laparoscopic distal partial gastrectomies have been performed. Although the laparoscopy-assisted proximal gastrectomy with gastroesophagostomy was previously reported, no studies have reported laparoscopic proximal gastrectomy with jejunal interposition. Such a lack of studies is likely caused by the procedure’s technical difficulty. We successfully performed completely laparoscopic proximal gastrectomy with jejunal interposition using a functional end to end anastomotic technique. We describe our new procedure and the initial clinical results in this article. METHODS