Characteristic submucosal alteration in biliary carcinogenesis of pancreaticobiliary maljunction with a focus on inflammasome activation.

Activated fibroblasts and M2 macrophages in the GB lamina propria may be associated with biliary carcinogenesis of PBM, possibly through inflammasome activation.

Compared with the control and cholecystitis groups, αSMA expression was higher in the cancerous part (stroma) of the GB in patients with GB cancer + PBM and in the lamina propria of patients with PBM. The CD204/CD68 ratio in the lamina propria was higher in the PBM group than in the control and cholecystitis groups. NLRP3 and caspase 1 expression in both the lamina propria and epithelium was higher in the PBM than control group. In the PBM group, NLRP3- and caspase 1-positive cells in the lamina propria were located near the epithelium.

Journal of Hepato-Biliary-Pancreatic Sciences


【先天性胆道拡張症up-to-date】胆嚢外瘻と手術術式

【先天性胆道拡張症up-to-date】胆嚢外瘻と手術術式


Risk factors for metachronous contralateral inguinal hernia after laparoscopic percutaneous extraperitoneal closure for unilateral inguinal hernia in children.

We use the laparoscopic percutaneous extraperitoneal closure (LPEC) method as the standard procedure for pediatric inguinal hernia. Despite judging there to be no contralateral patent processus vaginalis (PPV) at the time of the first LPEC, we experienced five cases in which metachronous contralateral inguinal hernia (MCH) developed, so we report the characteristics, including the predictors. For pediatric inguinal hernia, the LPEC method was used in 1277 cases from 2005 to 2019 in our department. Of these, 374 patients underwent unilateral LPEC, and we compared the 5 patients with MCH onset and the 369 without MCH onset. The items to be examined were the gender, age, presence of a low birth weight, initial-onset side, and contralateral internal inguinal ring classification. There was no significant difference in the gender, age, initial-onset side, or contralateral internal inguinal ring classification between the two groups. Low-birth-weight infants were significantly more common among those with MCH than among those without MCH. The only predictor of a contralateral onset after LPEC for pediatric inguinal hernia was a low birth weight. Therefore, for the above-mentioned unilateral LPEC cases, the possibility of a contralateral onset after LPEC due to acquired factors rather than congenital factors should be considered.


【小児外科疾患の家族内発生】側頸瘻

【小児外科疾患の家族内発生】側頸瘻


【消化管重複症のすべて】腹部食道

【消化管重複症のすべて】腹部食道


【シミュレーションとナビゲーション】胸腔鏡下肺葉切除術

【シミュレーションとナビゲーション】胸腔鏡下肺葉切除術


先天性胆道拡張症と膵・胆管合流異常

先天性胆道拡張症と膵・胆管合流異常


【慢性炎症から肝胆膵癌にいたるランドスケープ】膵・胆管合流異常と胆道癌

【慢性炎症から肝胆膵癌にいたるランドスケープ】膵・胆管合流異常と胆道癌


Treatment strategy for successful hepatic resection of icteric liver.

The treatment strategy for jaundiced patients with hilar cholangiocarcinoma (HC) is not well established. In this study, we evaluate the feasibility of our perioperative protocol for jaundiced patients with HC. Twenty patients with HC who underwent hepatic resection at our institute were enrolled, and patients were divided into icteric(n=6) and normal(n=14) group. As a perioperative protocol, Oral administration of Inchinkoto(ICKT), steroid and nafamostat mesilate were introduced. The evaluation of functional future remnant liver(FRL) by asiaroscintigraphy, and postoperative outcomes were retrospectively compared. Indocyanine green dye retention rate at 15 minutes was higher, and LHL15 values was lower in icteric group. However, in the functional evaluation of FRL, which was the sum of GSA uptake of the future FRL, there was no significant difference of LHL15 values of the remnant liver functional reserve between the two groups. As results, according to the difference of liver function, serum AST level was not different between two groups. The number of patients with postoperative morbidity in the two groups was comparable. Even in HC patients with icteric liver, accurate assessment of liver functional reserve and effective perioperative treatment may attribute to successful hepatectomy and favorable post-operative outcomes. J. Med. Invest. 65:37-42, February, 2018.

The Journal of Medical Investigation : JMI


Intrascrotal lipoblastoma: report of a case and the review of literature.

Intrascrotal lipoblastoma is a rare pediatric benign soft tissue neoplasm, and only 11 cases have been reported. The accurate preoperative diagnosis is difficult because of its rarelity and the similarity with the other soft tissue tumors. Among them, accurate preoperative diagnosis had been made in only one case. Thus, almost all of the cases had required inguinal mass excision (and orchidectomy in one case). In this paper, we discuss the accurate preoperative diagnosis of intrascrotal lipoblastoma and subsequent simple tumorectomy via minimal invasive scrotal skin incision, in 1-year-old boy. On physical examination, intrascrotal extra-testicular lobulated mass was palpated on the right scrotum. An ultrasonography revealed the well-circumscribed, iso-echoic, scant blood-flow, and lobulated tumors with each lobules of 1 to 4 cm in diameter, and the tumor located outside of the tunica vaginalis testis. The serum values of alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (b-hCG) were within normal limit. The preoperative diagnosis of intrascrotal lipoblastoma was made, and the mass was excised via minimal scrotal incision. The right testicle and epididymis were normal. The lesion consisted of the distinct two lobulated tumors, and microscopic examination confirmed the diagnosis of intrascrotal lipoblastoma. The postoperative course was uneventful without evidence of recurrence. A rare intrascrotal lipoblastoma is seldom made accurate preoperative diagnosis; however, the accurate preoperative suspicion of this tumor leads to the minimal invasive tumorectomy via scrotal skin incision and favorable postoperative recovery without recurrence.


The Kampo medicine "Daikenchuto (TU-100)" prevents bacterial translocation and hepatic fibrosis in a rat model of biliary atresia.

Biliary atresia is the most common cause of end-stage liver disease in children. It is known that bile duct ligation contributes to liver fibrosis via bacterial translocation (BT) and toll-like receptor 4 (TLR4) signaling of hepatic stellate cells (HSCs). We have reported previously that the traditional Japanese medicine, "Dai-kenchu-to (TU-100)," a form of "Kampo medicine" prevents BT in rats exposed to the stress of fasting. The aim of this study was to clarify the effect of TU-100 on a rat model of biliary atresia using bile duct ligation. Bile duct ligation and subsequent daily oral administration of TU-100 was performed in 6-week-old rats. The rats were killed at 3, 7, or 14 days after bile duct ligation to evaluate the liver injury, occurrence of BT, and hepatic fibrosis. As an in vitro experiment, we isolated fresh HSCs from the rats undergoing bile duct ligation. After cell attachment, TU-100 and its 3 component herbs (eg, processed ginger, ginseng radix, and Japanese pepper) were added, and the expressions of Alpha actin2 (acta2), Alpha-1 type I collagen (colIa1), and tissue inhibitor of metalloproteinase 1 (timp1) were analyzed. In vivo experiments demonstrated that oral administration of TU-100 decreased liver injury and atrophy of intestinal mucosa BT, hepatic fibrosis, and hepatic expression of alpha smooth muscle actin ( SMA) and TLR4, compared with rats that underwent bile duct ligation only. In vitro experiments showed that administration of TU-100 or the component herbs inhibited the expressions of acta2, colIa1, and timp1 in the HSCs. TU-100 prevented BT, activation of HSCs, and subsequent hepatic fibrosis. TU-100 may prevent progression of hepatic fibrosis in children with biliary atresia and improve prognosis.


【イラストでみる最新の胆・膵消化管吻合術】 肝管空腸吻合 先天性胆道拡張症，戸谷分類IV-A型


Effective use of a vessel-sealing system for laparoscopic unroofing of liver cysts.

Liver cysts that present with symptoms such as jaundice, abdominal pain, and intra-cystic infection require treatment. In laparoscopic unroofing of liver cysts, appropriate treatment is needed in cases where the cystic walls contain vessels or bile ducts. A vessel-sealing system can seal not only vessels, but also bile ducts. We experienced four cases in which laparoscopic unroofing of liver cysts was performed with a vessel-sealing system. Case 1 was a woman in her 70s who presented at our hospital with abdominal pressure. Abdominal CT showed liver cysts with a maximum diameter of 13 cm. Laparoscopic unroofing was performed with LigaSure Impact. Case 2 was a woman in her 50s with abdominal discomfort. CT showed a cyst 15 cm in diameter situated in the right lobe. We performed SILS using a LigaSure Blunt Tip to unroof the cyst. Case 3 was a man in his 80s with abdominal pain. CT showed a huge cyst 25 cm in diameter in the right lobe. We performed hybrid SILS with a LigaSure Blunt Tip to unroof the cysts. Case 4 was a woman in her 70s with upper abdominal pain. CT showed multiple cysts with a maximum diameter of 15 cm in the bilateral lobes. We performed hybrid SILS to successfully unroof her cysts. None of the cases experienced postoperative complications, such as bleeding or bile leakage, and none experienced recurrence of cysts. A laparoscopic unroofing using a vessel-sealing system can be a minimally invasive and safe treatment for liver cysts.


Clinical role of Foxp3+ regulatory T cell in Living donor related liver transplantation for prediction of life-threatening complications.

It is no doubt that regulatory T cells (Foxp3(+)CD4(+)CD25(+)T cells: Treg) play important roles in transplant immunity. We investigated the significance of Treg expression in acute stage of living donorrelated liver transplantation (LDLT) for the possibility of the sensitive marker for immunological state and homeostatic stress after liver transplantation. Peripheral blood was drawn from 5 recipients of LDLT preoperatively and on post operative 1, 4, 7, and 14 days. The peripheral blood mononuclear cells (PBMCs) were stained with CD4, CD25, Foxp3, and were analyzed with FACScan. This data was compared with clinical output of LDLT. The populations of Treg were significantly decreased in all patients on day 1 after LDLT and significantly increased in patients who had early postoperative complications compared with patients who had no complications. The population of Treg in peripheral blood may reflect the surgical stress such as life-threatening complications after LDLT.


Recovery pattern of non-protein respiratory quotient and non-esterified fatty acid after liver resection

Perioperative nutritional care is important to maintain preoperative and postoperative nutritional status. However, few reports have investigated energy metabolism after hepatectomy. The aim of this study was to determine differences in energy metabolism, blood biochemistry, and nutritional status before and after liver resection in patients with hepatocellular carcinoma (HCC) and healthy living donors for liver transplantation. Eighteen hospitalized patients with HCC group and 13 living donors for liver transplantation (donor group) were enrolled in this study. The donor group was divided into two groups on the basis of age; Y-donor group (age < 40 y, n = 7), and O-donor group (age ≥ 40 y, n = 6). Energy metabolism was measured by indirect calorimetry at preoperative day and postoperative day (POD) 7 and 14, and blood biochemistry was also examined. Recovery of non-protein respiratory quotient (npRQ) and blood biochemical data such as total bilirubin, aspartate aminotransferase and alanine aminotransferase levels were observed in Y-donor group on POD 14. However, although biochemical data improved in the HCC and O-donor group, npRQ remained unchanged on POD 14. Improvement of npRQ took longer than blood biochemical data in patients with HCC and older donors. Because the recovery of npRQ is associated with donor age, careful nutritional management may be required for a longer time depending on the pathophysiological condition of each patient after hepatectomy.


Beneficial effects of green tea catechin on massive hepatectomy model in rats.

BACKGROUND: Green tea catechin, especially epigallocatechin gallate (EGCG), is a well-known scavenger of reactive oxygen species and it may also function as an antioxidant through modulation of transcriptional factors and enzyme activities. METHODS: Green tea extract (GTE(®)) which contained numerous EGCG was used. Wistar rats were performed 90 % hepatectomy and classified into 2 groups with (GTEHx, n = 25) or without GTE treatment (Hx, n = 25) and sacrificed at 1, 3, 7 and 14 days after operations. All rats had free access to drinking water supplemented with or without GTE from the 7th pre-operative day. Liver regeneration, hepatic inducible nitric oxide synthase (iNOS), anti-oxidative enzymes [superoxide dismutase (SOD), catalase (CAT), glutathione peroxidase (GSH-Px)] and inflammatory markers [cyclooxygenase-2 (COX-2), nuclear factor kappa B (NFκB), tumor necrosis factor-α (TNF-α)] were investigated. RESULTS: The liver weight to body weight ratio (p < 0.01), proliferating cell nuclear antigen labeling index (p < 0.05) and phosphorylated extracellular signal-regulated kinase 1/2 (p < 0.05) at day 1 in the GTEHx group significantly increased compared to the Hx group. Hepatic iNOS levels at day 1 significantly decreased (p < 0.01) in the GTEHx group. Hepatic SOD, CAT and GSH-Px levels at day 1 significantly increased (SOD: p < 0.01, CAT and GSH-Px: p < 0.05) in the GTEHx group. In contrast, COX-2, NFκB and TNF-α levels at day 1 significantly decreased (COX-2: p < 0.01, NFκB and TNF-α: p < 0.05) in the GTEHx group. CONCLUSIONS: GTE pretreatment stimulated liver regeneration and improved liver damage after massive hepatectomy through anti-oxidative and anti-inflammatory effects. Green tea catechin might have the potential to attenuate liver dysfunction in early stage after massive hepatectomy.


Beneficial effects of enteral nutrition containing with hydrolyzed whey peptide on warm ischemia/reperfusion injury in the rat liver.

This study examined the efficacy of enteral nutrition containing hydrolyzed whey peptide (HWP) on warm ischemia/reperfusion (I/R) injury in the rat liver. Male Wistar rats were subjected to 30 min of warm hepatic ischemia followed by immediate p.o. intake of enteral nutrition with WHP (HWP group) or 20% glucose solution (control group) (0.025 mL/g). The animals were killed at 6 or 12 h after reperfusion. The serum aspartate aminotransferase (AST) and alanine aminotransferase alt (ALT) levels were measured. The necrotic areas were assessed histologically. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining and caspase-3 activation were assessed to evaluate apoptosis. The expressions of hepatic tumor necrosis factor (TNF)-α, interleukin (IL)-6 and nuclear factor (NF)-κB in the liver tissue were assessed by real time reverse transcription polymerase chain reaction. Significant reductions in the serum AST and ALT levels were seen in the HWP group compared with the control group at both 6 and 12 h after reperfusion. The necrotic areas and numbers of TUNEL positive cells were significantly decreased in the HWP group at 6 and 12 h after reperfusion. The caspase-3/7 activities were significantly decreased in HWP group at 6 and 12 h after reperfusion. The mRNA expressions of TNF-α and IL-6 were significantly reduced in the HWP group at 12 h after reperfusion. NF-κB mRNA expression was significantly increased in the HWP group at 6 and 12 h after reperfusion. Enteral nutrition containing HWP ameliorated the hepatic warm I/R injury possibly through the suppression of pro-inflammatory cytokine expressions and the induction of NF-κB in the rat liver.


肝切除支援ソフトによる術前シミュレーション，術中ナビゲーション，部分肝臓機能解析


縦隔腫瘍と鑑別を要した左肺葉外肺分画症の1例

縦隔腫瘍と鑑別を要した左肺葉外肺分画症の1例

Journal of the Japanese Society of Pediatric Surgeons


腹腔鏡補助下肝部分切除術を施行した肝芽腫の1例

腹腔鏡補助下肝部分切除術を施行した肝芽腫の1例


血流障害，遊走脾を伴った急性胃軸捻転症の1例

血流障害，遊走脾を伴った急性胃軸捻転症の1例


Effects of indole-3-carbinol and phenethyl isothiocyanate on bile and pancreatic juice excretion in rats.

Bile and pancreatic juice contain a number of parameters for cancer chemoprevention. Indole-3-carbinol (I3C) and phenethyl isothiocyanate (PEITC), which are hydrolytic products of brassica plants, have been established to be anti-cancer agents. Here, we developed a method for the continuous and selective sampling of bile and pancreatic juice, and the effects of I3C and PEITC on bile and pancreatic excretion and γ-glutamyl transpeptidase (γ-GTP) activity in the samples were investigated. Male Fisher 344 rats (eight weeks of age) were challenged intragastrically with I3C (150 mg/kg) or PEITC (160 mg/kg) for five days. Twenty-four hours after the final administration, cannulation was undertaken into the rats' bile and pancreatic ducts, and the bile and pancreatic juice were separately collected for 48 h. In this rat model, bile was stably excreted, and the bile and pancreatic excretion of the control rats was 21.9 ± 1.4 ml/48 h and 12.8 ± 1.7 ml/48 h, respectively. Bile excretion for the first 24 h significantly increased in the I3C- or PEITC-treated rats compared with the control rats. In the case of pancreatic juice, excretion during the first 24 h significantly increased in the PEITC-treated rats. In bile, γ-GTP activity was significantly increased for the first 24 h in the I3C- and PEITC-treated rats, but no difference was observed in the pancreatic juice. Increases of bile excretion and γ-GTP activity in bile might be a factor involved in the anti-cancer effect of I3C and PEITC. Our rat model described here is a useful tool for the study of cancer chemoprevention.

The Journal of Medical Investigation : JMI


Torsion of an accessory spleen with situs inversus in a child.

We present an unusual case of acute abdomen caused by torsion of an accessory spleen with situs inversus in a child. A three-year-old girl was admitted to our hospital with an 11-day history of right flank pain with fever. Her medical history revealed an operation of coarctation of the aorta with situs inversus at one month of age. Physical examination revealed a right flank mass and tenderness. A contrast-enhanced CT scan showed a normally enhanced small spleen in the right upper quadrant and a 7.0×6.0×3.5 cm, hypodense, marginal enhancing mass in the right midabdomen adjacent to the intestine. An emergency laparotomy was decided upon with a preoperative diagnosis as an acute abdomen. During surgery, a mass was found under the greater omentum and two accessory spleens of 1.5 cm in diameter were found surrounding the main spleen. Several loops of bowel were adherent to the mass. The loops of bowel were dissected away. A pediculated congested mass was observed as an accessory spleen emerging from the greater omentum. The mass was twisted on its vascular pedicle and strangulated. The necrotic mass was removed and the postoperative recovery was uneventful. Though torsion of an accessory spleen is extremely rare, it should be considered in the differential diagnosis of acute abdomen in childhood.


【内視鏡外科手術をめぐる最近のトピックス】 新たな領域への手術適応 保険収載後の腹腔鏡下肝切除術の展開


問題を有するドナーからの生体肝移植 ∼胃癌術後ドナーおよび喘息罹患ドナー∼.

問題を有するドナーからの生体肝移植 ∼胃癌術後ドナーおよび喘息罹患ドナー∼.

The Japanese journal of clinical and experimental medicine


急性肝不全に対する肝移植術施行のタイミングに難渋した症例

急性肝不全に対する肝移植術施行のタイミングに難渋した症例


Impact of splenectomy in patients with liver cirrhosis: Results from 18 patients in a single center experience.

Aim: With the recent advances in medical or surgical treatments in chronic hepatic disorders, the indications for splenectomy in hepatic disorders have greatly expanded. We performed splenectomy for cirrhotic patients and investigated the effects of splenectomy on hepatic functional reserve and nutrition metabolism. Methods: Eighteen patients (Child-Pugh B/C: 12/6; Child-Pugh A: excluded) who underwent splenectomy at our institute between 2005 and 2008 were enrolled. Twelve patients (67%) had hepatocellular carcinoma (HCC), eight of whom met the Milan criteria. Results: Overall survival rate was 83.3% at 1 year and 62.7% at 2 years. The survival rate of six patients with liver cirrhosis classified a Child-Pugh C was 80.0% at 1 year and 60.0% at 2 years. Three patients underwent hepatic resection and nine patients received ablation therapy against hepatocelluar carcinoma. Portal pressure decreased after splenectomy in most patients (mean decrease, 4.7 mmHg). Four weeks after the operation, the markers of hepatic functional reserve, indocyanine green retention rate at 15 min (ICGR15) and Technetium-99m-galactosyl human serum albumin value ((99m)Tc-GSA), improved from 38.5% to 35.1% and from 0.773 to 0.788 (LHL15), respectively. The non-protein respiratory quotient (npRQ) did not change in short period after the operation. Other outcomes, including liver function test in cirrhotic patients with long-term (1 year) follow-up after splenectomy (n = 7), did not improve significantly. Post-operative complications included portal thrombus (n = 2), ascites (n = 2) were observed in six patients (33%). Conclusion: Splenectomy improved hepatic functional reserve and nutritional metabolism in some cases. However, the long-term outcomes should still be evaluated.


ステロイド長期投与患者における周術期ステロイドカバー.

ステロイド長期投与患者における周術期ステロイドカバー.

In patients receiving chronic corticosteroid therapy, the adrenocortical function has decreased because of suppression of the hypothalamic-pituitary-adrenal axis. Under such a condition, it is easy to fall into a serious acute adrenocortical insufficiency during surgical stress. Corticosteroid supplementation is done as prevention of adrenocortical insufficiency. It is changing from corticosteroid supplementation of high dose into that of low dose that based on extrapolation from what constitutes a normal cortisol response to stress in recent years. On the other hand, some authors reported that patients receiving therapeutic doses of corticosteroids who undergo a surgical procedure do not routinely require corticosteroid supplementation so long as they continue to receive their usual daily dose of corticosteroid. Therefore, furthermore investigation should be necessary.


性差による肝胆膵疾患の臨床，病態，治療効果のDiscrepancy I.性差と各種肝疾患 7)肝移植と性差


肝癌ステージングと予後推定.

肝癌ステージングと予後推定.


メタボリックシンドロームと肝細胞癌

メタボリックシンドロームと肝細胞癌


腹腔鏡下肝切除:腹腔鏡下肝切除術における最近の話題 ∼気腹とガス塞栓∼.

腹腔鏡下肝切除:腹腔鏡下肝切除術における最近の話題 ∼気腹とガス塞栓∼.


乳癌が併存するレシピエント，高度脂肪肝ドナーという組み合わせに施行した生体肝移植.


血液型不適合肝移植後interferon治療に難渋したC型肝炎の1例

血液型不適合肝移植後interferon治療に難渋したC型肝炎の1例


【必携小児外科レジデントマニュアル2】倫理規定

【必携小児外科レジデントマニュアル2】倫理規定

<文献概要>はじめに 法は国家権力などによって強制される他律的な規範であり,守るべき最低限のルールである．一方,倫理は自主的な遵守が期待される自律的な規範である．これら2つは相反するものではなく互いに補完し合うべきもので,これまで「ヒポクラテスの誓い」に始まるさまざまな医の倫理が発展してきた．すなわち,医療を行うにあたり合理性をもって判断するために守るべき規範が医療倫理である．


【教科書にない小児外科疾患の最新情報-国内外の文献・ガイドラインから-】鼠径ヘルニア


【腹腔鏡下噴門形成術-新技術認定制度に向けて】ラップ形成(Nissen-Rossetti法)


Carcinogenic risk in the biliary epithelium of children with congenital biliary dilatation via the DNA damage repair pathway.

Congenital biliary dilatation (CBD) is a high-risk factor for biliary tract cancer (BTC). We previously reported the potential for carcinogenesis in the biliary epithelium of patients with CBD. In this study, we investigated potential carcinogenetic pathways, focusing on the DNA damage repair response, in children with CBD and compared the findings with those in adults. We enrolled 6 children with CBD and 10 adults with CBD without BTC who underwent extrahepatic bile duct resections, plus 4 control patients who underwent pancreaticoduodenectomy for non-biliary cancer. Levels of phosphorylated histone H2AX (γH2AX), MRE11, and Ku-70 in the biliary tract epithelium were evaluated by immunohistochemistry. The levels of γH2AX, MRE11, and Ku-70 were significantly higher in the gallbladder epithelium and bile duct epithelium of both children and adults than in controls. Children and adults with CBD might develop BTC via the DNA damage repair pathway, as evidenced by increased γH2AX, MRE11, and Ku-70 expression.


Risk of carcinogenesis in the biliary epithelium of children with congenital biliary dilatation through epigenetic and genetic regulation.

Congenital biliary dilatation (CBD), defined as pancreaticobiliary maljunction (PBM) with biliary dilatation, is a high risk factor for biliary tract cancer (BTC). KRAS and p53 mutations reportedly affect this process, but the mechanisms are unclear, as is the likelihood of BTC later in life in children with CBD. We investigated potential carcinogenetic pathways in children with CBD compared with adults. The subjects of this study were nine children with CBD and 13 adults with PBM (10 dilated, 3 non-dilated) without BTC who underwent extrahepatic bile duct resections, as well as four control patients who underwent pancreaticoduodenectomy for non-biliary cancer. We evaluated expressions of Ki-67, KRAS, p53, histone deacetylase (HDAC) and activation-induced cytidine deaminase (AID) in the biliary tract epithelium immunohistochemically. The Ki-67 labeling index (LI) and expressions of KRAS, p53, HDAC, and AID in the gallbladder epithelium were significantly higher or tended to be higher in both the children with CBD and the adults with PBM than in the controls. BTC may develop later in children with CBD and in adults with PBM, via HDAC and AID expression and through epigenetic and genetic regulation.


A case of Gross E esophageal atresia discovered following a unique clinical course.

The patient was a 15 months-old boy who had been diagnosed CHARGE syndrome, which is a multiple congenital anomaly syndrome caused by mutations in the CHD7 gene. Mechanical ventilation management was initiated 2 hours after birth for dysphagia and respiratory failure, and tracheotomy was performed 3 months after birth for dysphagia and failed extubation. He was repeatedly hospitalized due to pneuomoniae. Approximately 1 year after birth, the boy had two consecutive episodes of sudden ventilatory insufficiency while replacing the tracheotomy cannula. A bronchoscopic examination under general anesthesia revealed a tracheoesophageal fistula directly below the tracheostomy. The patient was diagnosed with Gross E esophageal atresia, and we speculated that the cannula migrated to the esophagus via the fistula during tracheostomy cannula replacement. Gross E esophageal atresia is a rare disease. Its diagnosis is often delayed, and it is discovered by recurrent pneumonia in many cases. A tracheoesophageal fistula may also be found in children with deformities of the respiratory system. Furthermore, tracheoesophageal fistulae are often found in the neck. Therefore, when sudden ventilatory insufficiency occurs in a child with a tracheostomy after replacing the tracheostomy cannula, caution must be exercised since the cannula may have migrated to the esophagus via a fistula. J. Med. Invest. 69 : 141-144, February, 2022.

The Journal of Medical Investigation : JMI


Bile Metabolites and Risk of Carcinogenesis in Patients With Pancreaticobiliary Maljunction: A Pilot Study.

Pancreaticobiliary maljunction (PBM), a disease with reflux of pancreatic and bile juice in the pancreaticobiliary tract, is a high-risk factor for biliary tract cancer. The aim of this study was to investigate the mechanism of carcinogenesis in PBM using a metabolomics analysis of bile sampled during surgery. Three patients with PBM without biliary tract cancer, four patients with extrahepatic bile duct cancer (EHBC), and three controls with benign disease were enrolled. Metabolomics analysis of bile samples was performed using capillary electrophoresis-mass spectrometry and liquid chromatography-mass spectrometry to discriminate the amino acid and lipidomic profiles. The principal component analysis in the capillary electrophoresis-mass spectrometry and liquid chromatography-mass spectrometry revealed similar metabolites in patients with PBM and those with EHBC; furthermore, there was a clear difference between patients with PBM or EHBC compared to controls. The amino acid profiles revealed the following 20 potential carcinogenic candidates for PBM: isoleucine, phenylalanine, tyrosine, leucine, tryptophan, arginine, lysine, valine, asparagine, methionine, aspartic acid, serine, threonine, histidine, glutamine, alanine, proline, glutamic acid, and pyruvic acid. The lipidomic profiles revealed the following 11 carcinogenic candidates: lysophosphatidylcholine, lysophosphatidylethanolamine, phosphatidyl glycerol, lysophosphatidyl glycerol, triacylglycerol, diacylglycerol, ceramide, sphyngomyeline, fatty acid, hyperforin, and vitamin D. Among these characteristic metabolites, the branched-chain amino acids, methionine and lysophosphatidylcholine are known to be related to carcinogenesis. The bile metabolites were extremely similar in patients with PBM and those with EHBC. Furthermore, amino acid and lipid metabolism was markedly different in patients with PBM or EHBC compared to healthy controls.


同時性・異時性に多発した小児脂肪芽腫の1例

同時性・異時性に多発した小児脂肪芽腫の1例

症例は3歳，男児．両側鼠径部外側と右背部の紡錘状の皮下腫瘤を認めたため，当科紹介受診となった．外来で経過観察を行っていたが，その後，左腋窩部及び右季肋部にも同様の皮下腫瘤が出現した．非典型的に多発し，悪性の可能性も否定できなかったため，背部皮下腫瘤を摘出し，脂肪芽腫と診断した．残りの4ヶ所を追加で切除したところ，最初の病変と同様に，脂肪芽細胞や小型の脂肪細胞を認め，同時・異時性に多発した脂肪芽腫と診断した．術後，約1年半が経過しているが，新たな腫瘤の発生や再発は認めていない．脂肪芽腫では，発見後の早期摘出が一般的であるが，稀に本症例のような多発例が存在することも念頭におき，早期摘出後も慎重な経過観察が必要であると思われた．(著者抄録)

Journal of the Japanese Society of Pediatric Surgeons


【そこが知りたいシリーズ:手術で必要な局所解剖(腹壁・後腹膜・泌尿器・腫瘍編)】大腿ヘルニア


【そこが知りたいシリーズ:手術で必要な局所解剖(腹部編)】PSARP(中間位直腸肛門奇形)


Impact of Bevacizumab on Liver Damage After Massive Hepatectomy in Rats.

The aim of this study was to evaluate the impact of pretreatment with bevacizumab on liver damage in a rat model of massive hepatectomy (Hx) model, as a surrogate model of massive Hx for liver metastasis from colorectal cancer. Male Wister rats (n=24) were separated into the following two groups: 90% Hx and 90% Hx plus bevacizumab group. Bevacizumab (5 mg/kg) was injected intraperitoneally 7 days before Hx. Samples of blood and remnant liver tissue were obtained 24 hours after hepatectomy and the following parameters were evaluated: Biochemical analysis; liver regeneration rate; survival rate; and real-time polymerase chain reaction for interleukin-1 beta (Il1b), tumor necrosis factor alpha (Tnfa), matrix metalloproteinase (Mmp) 2 and Mmp9 mRNA. In addition, samples of whole liver tissue were obtained immediately before Hx and real-time polymerase chain reaction was performed for X-box binding protein 1 (Xbp1), activating transcription factor 6 (Atf6), C/EBP homologous protein (Chop), glucose-regulated protein 78 (Grp78) and heat-shock protein 70 (Hsp70), as markers of endoplasmic reticulum stress response. The levels of transaminases 24 hours after Hx were significantly reduced in the group pretreated with bevacizumab compared to that not pretreated (p<0.05). The liver regeneration rate at 24 hours after Hx was significantly increased in the group pretreated with bevacizumab compared with the group which underwent Hx alone (p<0.05). The survival rate for the group pretreated with bevacizumab tended to be higher than that of the Hx-only group, 72 hours after Hx (p=0.09). The expressions of Il1b, Mmp2 and Mmp9 mRNA 24 hours after Hx in the group pretreated with bevacizumab tended to be lower than that of rats which underwent Hx alone (p=0.11, 0.09 and 0.15, respectively). The expression of Xbp1, Chop, Grp78 and Hsp70 mRNA immediately before Hx in the group pretreated with bevacizumab were significantly higher than the 90% Hx group (p<0.05). Bevacizumab pretreatment had protective effects on liver injury after massive hepatectomy in rats, apparently via the induction of the endoplasmic reticulum stress response, i.e. the so-called unfolded protein response.


Laparoscopic resection of hepatoblastoma: report of a case.

Despite the increasing number of recent reports on laparoscopic resection of malignant liver tumors in adults, there have been few reports involving children. In this paper we discuss the laparoscopic resection of a hepatoblastoma in a 1-year-old boy. The CT scan revealed an exophytic hepatic tumor on S5 measuring 6 × 5 × 4 cm after preoperative chemotherapy. The operation time was 225 min with an estimated blood loss of about 38 mL; intraoperative transfusion was not required. Radiofrequency-assisted precoagulation was performed. The patient had an uncomplicated recovery and started postoperative chemotherapy on postoperative day 12. Our literature search revealed only five reported cases of laparoscopic resection of hepatoblastoma in which there was no postoperative complication or recurrence. Laparoscopic resection of a hepatoblastoma in a selected subgroup of patients can be safe and feasible.


The Role Of Surgical Treatment In The Multidisciplinary Therapy For Hepatoblastoma.

The aim of this study was to evaluate the clinico-patholigical features and effects of multi-disciplinary therapy for pediatric patients with hepatoblastoma (HB). Ten cases who underwent hepatectomy from 1996 to 2013 were studied. Our therapeutic protocol included neoadjuvant chemotherapy (NAC) + hepatectomy + adjuvant chemotherapy (AC). The regimens were CDDP+THP-ADR (n = 2), CITA (n = 1), PLADO (n = 5), and CDDP(n = 1). One case with 18-trisomy underwent only hepatectomy. Medical records were reviewed to evaluate characteristics, the effects of chemotherapy and prognosis. The median age at operation was 1.2 years (male: 7 and female: 3). PRETEXT classification was assigned to groups I (n = 2), II (n = 4), and III (n = 4). 15 years overall survival and disease-free survival rates were 100% and 80%, respectively. Two cases, who had post-operative lung metastasis, underwent chemotherapy with or without complete resection of lung tumors. No further recurrence was observed in these two cases. One case with 18 trisomy underwent right hepatectomy for PRETEXT II HB and is still doing well 67 months after hepatectomy. It was found that multidisciplinary therapy based on surgery, including complete resections of recurrent lesions, offers long-term survival, even for cases which develop recurrent metastatic tumors or cases complicated with 18 trisomy.


Indigo carmine dye-assisted lymphatic-sparing laparoscopic Palomo varicocelectomy in children.

The ideal method for varicocelectomy in children remains controversial. We present our experience with dye-assisted lymphatic-sparing laparoscopic varicocelectomy (LSLV) in children, which overcomes the limitations of previously described techniques. Five consecutive LSLVs were performed over a period of three years on children with a mean age of twelve years. The varicocele grade was three in one case and grade 2 in four cases, respectively. A left subdartos injection of 2 ml of Indigo carmine dye was done using a 25-gauge needle at ten minutes before an operation. A scrotal injection of lymphatic dye was utilized to spare at least one lymphatic and the remaining spermatic vessels were divided. Lymphatic-sparing was accomplished in all cases. No peri-operative complication was noted. We spared one lymphatic channel in one patient (20%) and two channels in four patients (80%). There were no cases of hydrocele or residual varicocele. Dye-assisted LSLV is easily accomplished with an excellent surgical outcome and sparing one or two lymphatics appears to be sufficient to avoid secondary hydrocele.


Iliopsoas abscess (IPA) is uncommon in childhood and very rare in the neonate and infant. We present a case of IPA after an umbilical granuloma in an infant. A baby girl with a birth weight of 2,970 g was born at thirty-seven weeks and two days gestation by Caesarean Section. On the fourteenth day after birth, her umbilicus was wet and developed the granulomatous formation. At two months of age, she presented with right leg and groin swelling with mild bluish discoloration and without fever. She had poor movement of her right leg and showed apparent discomfort. Her umbilicus was dry and there was no granulomatous material. Ultrasonography and computed tomography demonstrated an iliopsoas abscess in the right position. Therefore, an extraperitoneal surgical drainage was performed, aspirating yellowish pus. Culture of the purulent material revealed Staphylococcus aureus. Systemic antibiotic therapy was continued for ten days. After three days of drainage, full-range motion of the right leg was gained, and then after eleven days, CT findings comfirmed the disappearance of the iliopsoas abscess. IPA is extremely rare and it is difficult to diagnose. However, it should be included in the differential diagnosis of an infant with poor leg movement and swelling of the groin to the femur.


CXC receptor 4 and stromal cell-derived factor 1 in primary tumors and liver metastases of colorectal cancer.

It has been determined that the chemokine receptor CXC receptor 4 (CXCR4) and its ligand, stromal cell-derived factor 1 (SDF-1), regulate several key processes in a wide variety of cancers. In this study, we investigate the possible role of SDF-1 (noncancerous liver tissue) and CXCR4 in liver metastases of colorectal cancer (CRC). Reverse transcription-polymerase chain reaction was performed to examine the expression of SDF-1 in noncancerous liver tissues of 16 CRC patients with liver metastasis and in normal liver tissues of six patients with benign liver disease. We also examined the expression of CXCR4 in cancerous tissues from primary and metastatic tumors. Using reverse transcription-polymerase chain reaction, CXCR4 expression in metastatic tumors tended to be higher than that in primary tumors (P = 0.16). High CXCR4 expression in a primary tumor was found to be related to an increased lymphatic invasion (P = 0.01), an advanced depth of tumor invasion (P = 0.07), and a decrease in the overall survival rate. The SDF-1 expression observed in noncancerous liver tissues of CRC with liver metastasis was significantly higher than that observed in normal liver tissues of benign liver disease (P < 0.05). In CRC with liver metastasis, CXCR4 expression demonstrated associations with local progression, liver metastasis, and poor overall survival.


The role of Aurora B expression in non-tumor liver tissues of patients with hepatocellular carcinoma.

Aurora B is a serine-threonine kinase and chromosomal passenger protein involved in the control of chromosome assembly and segregation during mitosis. Aberrant expression of Aurora B has been reported in some tumors, including lung and hepatocellular carcinoma (HCC). We investigated the role of Aurora B expression in both HCC and matched adjacent non-tumor tissue. Sixty-three patients with HCC who underwent hepatic resection were enrolled in this study. Aurora B expression in tumor and non-tumor tissue was examined by use of quantitative reverse transcription-polymerase chain reaction. The patients were divided into high and low gene expression groups by median value, and clinicopathological data were compared between the two groups. Aurora B expression was significantly higher in tumor tissue than in non-cancerous tissue (P < 0.001). Disease-free survival was not significantly different between groups with high and low expression in the tumor tissues. For non-tumor tissues, disease-free survival of the low-expression group was significantly better than that of the high-expression group (P < 0.05). The gene expression level of Aurora B correlated with results from liver function tests, for example prothrombin time. Aurora B expression in non-cancerous tissues may be a prognostic factor for HCC.

International Journal of Clinical Oncology