Journal of hepato-biliary-pancreatic surgery最新文献

The epigenetic makeup of organisms forms a link between the genetic information (DNA sequence) and the gene expression (and therefore phenotype). It dictates the memory for the gene expression pattern that, in turn, specifies cell identity. DNA methylation is the most studied epigenetic mechanism, aberration of which prevails in cancer, resulting in an altered pattern of gene expression and, therefore, cancerous features, including genetic abnormalities: mutations and genome instability. Altered methylation in cancer occurs in two directions. A marked reduction in the overall level of DNA methylation has been linked to the activation of transcription/transposition and the overexpression of protooncogenes. In parallel, there is a common occurrence of a hypermethylated status of the promoter cytosine (CpG) island in genes involved in the negative control of cell growth and in the maintenance of genomic stability; therefore causing transcription silencing. It is thus necessary and important to establish a comprehensive profile of DNA methylation changes in the promoter CpG island in many genes, both for better understanding of the underlying mechanisms and for diagnostic purposes in cancer clinics. Hepatocellular carcinoma is one of the most threatening malignancies in East Asia and Africa. In this short review, I briefly outline our current understanding of DNA methylation in cancer in general, emphasizing its recent progress in hepatocellular carcinoma.

We believe that this is the first report of a retroperitoneal tumor consisting of heterotopic gastrointestinal mucosa and pancreatic tissue. The patient was a 19-year-old woman with the chief complaint being occasional back pain. Abdominal computerized tomography demonstrated a 3.1 x 2.5 x 3.2-cm low-density solid and cystic lesion adjoining the left renal vein between the aorta and inferior vena cava. Angiography revealed that the inferior vena cava was displaced by the hypovascular tumor. The retroperitoneal lesion was diagnosed preoperatively as a benign tumor such as a neurogenic neoplasm or lymphangioma. At laparotomy, a cystic tumor was found, which existed behind the inferior vena cava and renal vessels, and contained reddish-brown fluid, suggesting hemorrhage in the past. The cut surface of the tumor showed a unilocular cyst with partially hypertrophic wall. Histopathological examination revealed a cystic tumor lined with heterotopic gastric and duodenal mucosa, with pancreatic tissue in the muscularis propria. In addition, evidence of bleeding from the gastric mucosa was observed in the cystic tumor. External secretion from these tissues could have triggered the hemorrhage and expanded the tumor, possibly resulting in the back pain.

The treatment of intraductal papillary mucinous tumors (IPMT) of the pancreas is still controversial. In this report we describe a single-branch resection of the pancreas (SBRP), which is a new method for the removal of branch-type IPMT of the head of the pancreas. A multilobular cystic lesion (50 x 40 mm) in the head of the pancreas was incidentally detected in an asymptomatic 40-year-old man who underwent a routine ultrasound examination. The tumor was carefully removed along the border of the cyst and the normal parenchyma, with complete preservation of the main pancreatic duct and the common bile duct. A pancreatic fistula developed during the postoperative period, but was well-controlled by endoscopic naso-pancreatic drainage. SBRP is a technically feasible procedure and this operation represents a minimally invasive alternative to any other segmental resection of the pancreas.

This author has personally carried out in excess of 700 major hepatic resections for tumor, and runs a unit with a current resection rate of 200 per year, yet uses no scientific tests designed to judge hepatic reserve. In our unit, we have an advantage in that we deal with a northern European population, with a low rate of viral hepatitis, although alcoholism is becoming an increasing feature within our practice and we are dealing with more elderly patients that in the past, and more who have undergone neoadjuvant chemotherapy. In these patients, there appear to be greater risks of postoperative sepsis and slower regeneration. Approximately 65% of our current resection practice is hemihepatectomy or more and the majority is trisectionectomy (extended hepatectomy) and bilateral resection work. Preoperative, operative, and postoperative factors affect the occurrence of postoperative hepatic failure and these aspects are considered. Case series studies are presented to illustrate the incidence of significant hepatic failure we have encountered.

The main goal of liver resection in patients with liver tumor is to cure the patients with the lowest operative risk. Based on our experiences, we report herein, indications of liver resection according to the nature of underlying liver parenchyma. In patients with normal underlying liver parenchyma, major resection does not require specific preoperative assessment. Non-tumorous biopsy is indicated in cases of massive steatosis and/or in patients in whom a complex technical procedure is anticipated. Portal vein embolization (PVE) is considered if the future liver remnant (FLR) is < 30%. In patients with chronic liver disease, major hepatectomy is a risky situation, requiring specific preoperative assessment, including non-tumorous biopsy and PVE which could be associated with transarterial chemoembolization. Absence of hypertrophy of the FLR after PVE is a contraindication to a major hepatectomy. Intraoperative procedures in patients "at risk" require specific techniques, including intermittent clamping, anterior approach with hanging maneuver, and fixation on anatomical position of the remnant liver.

Background/purpose: The aim of this study is to evaluate a new scoring system, called the chronic liver dysfunction (CLD) score, for prediction of the surgical risk of partial hepatectomy in patients with chronic liver damage. Morbidity and mortality rates after gastroenterological surgery are high in patients with hepatic cirrhosis. Accordingly, it is very important to assess the surgical risk in such patients before surgery. Although the Child classification (or Child-Pugh score) has been a standard system, it did not always accurately predict patients at the risk of mortality after gastroenterological surgery, especially partial hepatectomy.

Methods: In 1985, we established a new system called the CLD score, reviewing the patients undergoing gastroenterological operations at one hospital. In the present study, we prospectively used the CLD score in 256 consecutive patients with chronic liver dysfunction who were treated surgically by partial hepatectomy, and investigated the usefulness of the CLD score concerning mortality. The results were compared with those of the Child-Pugh score (C-P score).

Results: After major hepatectomy, all the patients with CLD score exceeding 1.5 died of hepatic failure. After minor hepatectomy, all the patients with CLD score exceeding 2.5 died of hepatic failure. On the other hand, C-P score did not predict the outcome in these patients.

Conclusions: Compared with the C-P score, which was considered the gold standard scoring system for assessing surgical risk for patients with chronic liver dysfunction, our CLD score provides a more reliable assessment of the risk of partial hepatectomy.

Background/purpose: Hepatic resection may result in liver failure in patients with cirrhotic livers. Preoperative evaluation of liver function in cirrhotic patients, to prevent postoperative liver failure, is very important.

Methods: Sixteen patients with hepatocellular carcinoma in cirrhotic livers were enrolled in this study. Liver function was determined quantitatively by monoethylglycinexylidide (MEGX) formation from the metabolism of lidocaine. The whole liver volume and tumor volume were measured by computed tomographic volumetry. The volume of resected liver was recorded by water displacement. The relationship between liver function and remnant liver volume was determined.

Results: A relationship between the percentage remnant liver volume and ratio of MEGX formation after hepatectomy was found. The regression equation was: (postoperative MEGX formation/preoperative MEGX formation) x 100% = (0.688 x percentage remnant liver volume + 0.179) x 100% (r (2) = 0.49). A relationship between MEGX formation after hepatectomy and the international ratio (INR) of prothrombin time was also found. The regression equation was INR = 1.99 - 0.01 x MEGX (r (2) = 0.30).

Conclusions: Post-hepatectomy liver function can be estimated for an individual patient by the appropriate regression equations. Prevention of post-hepatectomy liver failure for patients with cirrhotic livers is feasible.

We report a patient with a minute nonfunctioning islet cell tumor, 8 mm in diameter, which demonstrated malignant features by histology. The patient was a 43-year-old Japanese woman, who had an elevated carbohydrate antigen (CA) 19-9 level, of 59 U/ml (normal range, <37 U/ml) identified on a health check to rule out malignancies. Ultrasonography and computed tomography demonstrated a well-defined pancreatic tumor, 8 mm in diameter, in the body of the pancreas. Serum levels of pancreatic hormones were within normal limits, and thus a tentative diagnosis was nonfunctioning islet cell tumor. The size of the tumor remained unchanged for 1 1/2 years, but, at this time, the serum level of CA19-9 was elevated to 253 U/ml. Segmental pancreatectomy was performed because malignancy could not be ruled out. The resected specimen showed an endocrine tumor invading both the pancreatic parenchyma and the perineural spaces outside the tumor. In general, minute nonfunctioning islet cell tumors have been considered to be completely benign, but the present tumor showed clear malignant features. We might have to take surgical resection into consideration even if the size of such an endocrine tumor is minute.

Recent observations suggest that an immune response is involved in the development of chronic pancreatitis. We report a case of autoimmune pancreatitis in a patient who showed complete obstruction of the lower common bile duct. A 63-year-old man was admitted to a local hospital, complaining of appetite loss and back pain. The patient had obstructive jaundice, and percutaneous transhepatic gallbladder drainage was performed. Fluorography through the biliary drainage catheter showed complete obstruction of the lower common bile duct. The patient had no history of alcohol consumption and no family history of pancreatic disease. Physical examination revealed an elastic hard mass palpable in the upper abdomen. Abdominal ultrasound and abdominal computed tomography (CT) scans showed enlargement of the pancreas head. While autoimmune pancreatitis was highly likely, due to the patient's high serum immunoglobulin level, the possibility of carcinoma of the pancreas and/or lower common bile duct could not be ruled out. Laparotomy was performed, and wedge biopsy samples from the pancreas head and body revealed severe chronic pancreatitis with infiltration of reactive lymphocytes, a finding which was compatible with autoimmune pancreatitis. Cholecystectomy and biliary reconstruction, using choledochojejunostomy, were performed, because the complete bile duct obstruction was considered to be irreversible, due to severe fibrosis. After the operation, prednisolone (30 mg/day) was given orally for 1 month, and the entire pancreas regressed to a normal size. Complete obstruction of the common bile duct caused by autoimmune pancreatitis has not been reported previously; this phenomenon provides an insight into autoimmune pancreatitis and provokes a controversy regarding whether biliary reconstruction is needed for the treatment of complete biliary obstruction caused by autoimmune pancreatitis.