Shintaro Yamazaki

Sera from liver failure patients and a demethylating agent stimulate transdifferentiation of murine bone marrow cells into hepatocytes in coculture with nonparenchymal liver cells

BACKGROUND/AIMS The plasticity of bone marrow cells (BMCs) is shown by their ability to differentiate into mesenchymal as well as endodermal and ectodermal lineages. Transdifferentiation of BMCs into hepatocytes has also been demonstrated, both in vitro and in vivo. In the present study we investigated the effects of liver nonparenchymal cells (NPCs) and sera from liver failure patients (HSLF) on the in vitro transdifferentiation of murine BMCs into hepatocytes. METHODS Liver NPCs from wild-type mice, and 5-azacytidine-treated BMCs from green fluorescence protein transgenic mice, were cocultured in medium containing HSLF in combination with several cytokines. Hepatocyte-specific gene expression in BMCs was identified by immunocytochemistry and reverse transcription-polymerase chain reaction. RESULTS Bone marrow cell-derived hepatocyte-like colonies appeared after several days of coculture in medium containing HSLF, oncostatin M (OSM) and hepatocyte growth factor (HGF). These colonies expressed hepatocyte-specific genes. Transdifferentiation was enhanced by 5-azacytidine treatment, and by HSLF, OSM and HGF. It did not take place when the BMCs were separated from the NPCs in a dual chamber dish, or cultured with other mesenchymal cells. CONCLUSIONS Direct interaction of murine BMCs with liver NPCs, as well as soluble factors in the HSLF and a demethylating agent, strongly stimulate transdifferentiation into hepatocytes.

Criteria for drain removal following liver resection

Abdominal drains have been placed prophylactically and removed in liver resection without robust evidence. The present study was designed to establish the optimal time for removal of such drains.

Validation of perioperative steroids administration in liver resection: a randomized controlled trial.

Objective:We performed a randomized controlled trial to investigate the clinical benefits of perioperative treatment with steroids in patients undergoing liver resection. Background:Perioperative steroids are considered to reduce surgical stress, but evidence supporting proposed clinical benefits is largely anecdotal. Patients and Methods:The 210 patients scheduled to undergo liver resection were randomly assigned to a steroids group (n = 105) or a control group (n = 105). The steroids group received 500 mg hydrocortisone immediately before hepatic-pedicle clamping, followed by 300 mg hydrocortisone on postoperative day (POD) 1, 200 mg on POD 2, and 100 mg on POD 3. Serum levels of total bilirubin, aminotransferases coagulation factors, and inflammatory-related cytokines, and the clinical course were compared between the 2 groups. The primary end point was the postoperative bilirubin level. Results:All 210 patients underwent radical liver resection with no operative mortality. The median bilirubin level on POD 2 was significantly lower in the steroids group [0.71 mg/dL (0.33–2.17)] than in the control group [1.03 mg/dl (0.39–3.57); P = 0.01]. The postoperative time courses of the bilirubin level (P = 0.01), the interleukin-6 level (P = 0.01) and the C-reactive protein level (P = 0.01) were significantly lower whereas the the prothrombin level (P = 0.01) and interleukin-10 level (P = 0.01) were significantly higher in the steroids group. There was no difference between the groups in the proportion of patients with complications (40% vs 43%; P = 0.66) or the length of the hospital stay (14 days vs 13 days; P = 0.68). Conclusions:Perioperative treatment with steroids has a positive impact on the liver function of patients who undergo liver resection, without increasing the risk of complications.

Acute Appendicitis in an Incarcerated Femoral Hernia: A Case of De Garengeot Hernia.

Appendicitis and incarcerated hernia are frequently encountered reasons of emergency surgery for acute abdomen. The treatment in early stages of each condition is generally simple, but when these conditions are combined, the symptoms become slightly complicated, obscuring specific symptoms. Especially the lack of symptoms for appendicitis leads to delayed diagnosis, resulting in high morbidity. Amyand hernia, which contains appendix in its inguinal hernia sac, is perhaps more familiar to the general surgeons than De Garengeot hernia, which is an incarcerated femoral hernia with an appendix in its sac. We report the case of a 90-year-old female with incarcerated femoral hernia who underwent emergency hernioplasty only to reveal an inflamed appendix in its sac. The patient underwent both appendectomy and hernia repair simultaneously with synthetic mesh and was discharged on postoperative day 7 without any complications. We will also discuss the physical and radiological findings of De Garengeot hernia.

Transfusion Criteria for Fresh Frozen Plasma in Liver Resection: A 3 + 3 Cohort Expansion Study

OBJECTIVE To establish transfusion criteria for use of fresh frozen plasma (FFP) in liver resection. BACKGROUND Fresh frozen plasma has been transfused in liver resection without adequate supporting evidence, leading to unnecessary use. DESIGN Prospective study using a phase 1 dose-escalation, 3 + 3 cohort expansion design, modified for FFP transfusion. We designated a serum albumin level of 3.0 g/dL (step 1) as the starting limit for no transfusion and reduced the level in 0.2-g/dL steps. Advancement to the next step was permitted when the albumin level equaled the target value for the previous step in 3 patients. If the albumin value on postoperative day 2 fell below the target value, 100 mL of albumin, 25%, was transfused on that day and on postoperative day 3. The study continued until high-grade postoperative complications occurred without transfusion. If 1 of 3 patients developed Clavien-Dindo grade II or higher complications, 3 more patients (3 + 3 cohort) were added to the same step. SETTING Hepatobiliary pancreatic surgery center of a university hospital. PATIENTS Patients with hepatocellular carcinoma who had had Child-Pugh class A liver function and an intraoperative blood loss of less than 1000 mL. INTERVENTION Transfusion or no transfusion of FFP. Main Outcome Measure Reduction of transfusion rate in liver resection. RESULTS Of the 213 consecutive patients with liver cancer enrolled, 172 patients (80.8%) fulfilled the inclusion criteria. Step progression proceeded until step 5 (albumin level, 2.2 g/dL) without high-grade complications, but step 2 (albumin level, 2.8 g/dL) required 63 patients to complete because 1 patient developed grade II complications (massive ascites). Step progression was broken off at step 5 in the 172nd patient because the postoperative day 2 albumin value did not fall below the step 4 level (2.4 g/dL), defined as the goal limit. The overall operative morbidity rate was 27.9%; the mortality rate was 0%. The FFP transfusion rate was significantly reduced from 48.6% in a previous series involving 222 patients (unpublished historical data from our institution) to 0.6% (1 of 172 patients) in the present study (P < .001). The postoperative hospital stay in the present study was significantly shorter than that in our previous series (13 vs 16 days; P = .01). Total medical costs were significantly reduced from a median of

Early cancer-related death after resection of hepatocellular carcinoma

21 061 (range, 10 032-59 410) to

Activation of WNT/β-Catenin Signaling Enhances Pancreatic Cancer Development and the Malignant Potential Via Up-regulation of Cyr61

17 267 (11 823-35 785; P = .04). CONCLUSION In liver resection, FFP transfusion is not necessary in patients with serum albumin levels higher than 2.4 g/dL on postoperative day 2.

Splenocytes can replace chimeric cells and maintain allograft tolerance.

BACKGROUND Surgeons have attempted to prevent early cancer-related death after resection of hepatocellular carcinoma to identify risk factors associated with early death from hepatocellular carcinoma recurrence after liver resection. METHODS The study group comprised 350 patients who had undergone liver resection for hepatocellular carcinoma between 1997 and 2007. The preoperative risk factors for early death from intrahepatic recurrence (within 1 year after resection) were evaluated. RESULTS Fourteen (4%) patients died of intrahepatic recurrence in the first year after resection. Multivariate analyses identified the following risk factors for early cancer-related death: multiple tumors (odds ratio 10.4; 95% confidence interval, 2.42-44.3; P = .002), vascular invasion (odds ratio 10.1; 95% confidence interval 2.07-50; P = .004), serum alpha-fetoprotein level >20 ng/mL (odds ratio 9.52; 95% confidence interval 1.0--84.2; P = .043), and tumor size ≥50 mm (odds ratio 4.80; 95% confidence interval 1.06-21.9; P = .042). Each of these factors was assigned a score of 1 point, and an algorithm was developed to predict the risk of early death. Outcomes did not differ significantly between patients with 3 or 4 points (P = .48) or between those with 1 or 2 points (P = .49). Patients who underwent liver resection could be stratified into the following distinct groups according to the point score and the associated 1-year survival rate and median survival (shown respectively): 0 points, 99%, and not yet; 1 or 2 points, 96%, and 68 months; and 3 or 4 points, 50%, and 12 months) (P < .0001). CONCLUSION Even if hepatocellular carcinoma is resectable, patients with a score of 3 or 4 points may not be good candidates for liver resection.

The technical advance and impact of caudate lobe venous reconstruction in left liver: additional safety for living-related donor liver transplantation.

Pancreatic ductal adenocarcinoma (PDAC), a poor prognostic cancer, commonly develops following activating mutations in the KRAS oncogene. Activation of WNT signaling is also commonly observed in PDAC. To ascertain the impact of postnatal activation of WNT-stimulated signaling pathways in PDAC development, we combined the Elastase-tva-based RCAS-TVA pancreatic cancer model with the established LSL-KrasG12D, Ptf1a-cre model. Delivery of RCAS viruses encoding β-cateninS37A and WNT1 stimulated the progression of premalignant pancreatic intraepithelial neoplasias (PanIN) and PDAC development. Moreover, mice injected with RCAS-β-cateninS37A or RCAS-Wnt1 had reduced survival relative to RCAS-GFP-injected controls (P < .05). Ectopic expression of active β-catenin, or its DNA-binding partner TCF4, enhanced transformation associated phenotypes in PDAC cells. In contrast, these phenotypes were significantly impaired by the introduction of ICAT, an inhibitor of the β-catenin/TCF4 interaction. By gene expression profiling, we identified Cyr61 as a target molecule of the WNT/β-catenin signaling pathway in pancreatic cancer cells. Nuclear β-catenin and CYR61 expression were predominantly detected in moderately to poorly differentiated murine and human PDAC. Indeed, nuclear β-catenin- and CYR61-positive PDAC patients demonstrated poor prognosis (P < .01). Knockdown of CYR61 in a β-catenin-activated pancreatic cancer cell line reduced soft agar, migration and invasion activity. Together, these data suggest that the WNT/β-catenin signaling pathway enhances pancreatic cancer development and malignancy in part via up-regulation of CYR61.

Subcutaneous drainage to prevent wound infection in liver resection: a randomized controlled trial.

Background. The induction of donor-specific tolerance (DST) has recently attracted widespread attention as a new approach to facilitate engraftment without using immunosuppressants. One way in which to induce DST is to establish a chimeric state that allows donor-derived cells to exist within a recipient. This study aims to investigate whether splenocytes can be used to maintain chimerism and to prolong graft survival. Methods. Mixed bone marrow (BM) was established in this chimeric model by lethally irradiating C3H mice on day 0, and transplanting BM from C3H and B6D2F1 mice into them. Skin grafts from C57BL/6 mice were transplanted on day 30. On day 60, splenocytes from C3H (group A), B6D2F1 (group B) and B6C3F1 (group C) mice were administered to the chimeric mice. The class I major histocompatibility complex (MHC) type, the percentage of chimeric cells in the peripheral blood, and the survival of skin grafts were assessed. Results. After splenocyte infusion, BM-derived chimeric cells were eliminated from the periphery in group A (86.2±5.9% to 0.04±0.03%, P=0.0008), B6D2F1-derived cells increased in quantity and established an allochimera in group B (83.7±7.2% to 99.6±0.2%, P=0.021), and in group C the B6C3F1-derived cells significantly increased to a level of 77.8% at 180 days after infusion (P=0.014), thereby maintaining the new chimerism. Skin grafts in groups B and C survived for at least 200 days (P=0.0003 and P=0.0001, respectively). Conclusions. Chimerism arising from cells with a partial MHC match to the graft allows the maintenance of specific immunotolerance and graft survival.