Hepatoprotection of a Standardized Extract of Cultured Lentinula edodes Mycelia against Liver Injury Induced by Ischemia-Reperfusion and Partial Hepatectomy

A standardized extract of cultured Lentinula edodes mycelia (ECLM, AHCC®) has been shown to have beneficial effects on organ metabolism. ECLM has been indicated to have liver protective properties by suppressing inflammatory responses. The pathogenesis of hepatic ischemia-reperfusion injury is thought to involve the induction of inflammatory mediators. However, whether ECLM affects inflammatory mediators caused by warm hepatic ischemia-reperfusion injury and partial hepatectomy (HIRI+PH) has not been clarified. In this study, we evaluated the protective effects of ECLM against liver damage caused by HIRI+PH. Rats were fed a normal diet (HIRI+PH) or a normal diet with 2% ECLM (HIRI+PH and ECLM) for ten days, then the liver and duodenal ligament were clamped and subjected to 15 min of hepatic ischemia. After 70% hepatectomy, the inflow occlusion was released, and liver and blood samples were collected at 3, 6, and 24 h. The effect of ECLM on mortality induced by 30 min of ischemia and hepatectomy was evaluated. The results showed that ECLM attenuated pathological liver damage, including apoptosis, in the rats treated with HIRI+PH, and decreased serum aminotransferase activity; ECLM decreased mRNA levels of the inflammation-related genes inducible nitric oxide synthase and C-X-C motif chemokine ligand 1, and increased mRNA levels of interleukin 10, an anti-inflammatory cytokine; ECLM increased hepatocyte growth factor mRNA levels and Ki-67 labeled nuclei in the liver at 24 h; ECLM significantly reduced HIRI+PH-induced mortality. In conclusion, ECLM may prevent HIRI+PH-induced liver injury in part by suppressing various inflammatory responses and promoting liver regeneration.

Sulforaphane Is Protective against Warm Ischemia/Reperfusion Injury and Partial Hepatectomy in Rats

Sulforaphane (SFN) has various beneficial effects on organ metabolism. However, whether SFN affects inflammatory mediators induced by warm hepatic ischemia/reperfusion injury (HIRI) is unclear. To investigate the hepatoprotective effects of SFN using an in vivo model of HIRI and partial hepatectomy (HIRI + PH), rats were subjected to 15 min of hepatic ischemia with blood inflow occlusion, followed by 70% hepatectomy and release of the inflow occlusion. SFN (5 mg/kg) or saline was randomly injected intraperitoneally 1 and 24 h before ischemia. Alternatively, ischemia was prolonged for 30 min to evaluate the effect on mortality. The influence of SFN on the associated signaling pathways was analyzed using the interleukin 1β (IL-1β)-treated primary cultured rat hepatocytes. In the HIRI + PH-treated rats, SFN reduced serum liver enzyme activities and the frequency of pathological liver injury, such as apoptosis and neutrophil infiltration. SFN suppressed tumor necrosis factor-alpha (TNF-α) mRNA expression and inhibited nuclear factor-kappa B (NF-κB) activation by HIRI + PH. Mortality was significantly reduced by SFN. In IL-1β-treated hepatocytes, SFN suppressed the expression of inflammatory cytokines and NF-κB activation. Taken together, SFN may have hepatoprotective effects in HIRI + PH in part by inhibiting the induction of inflammatory mediators, such as TNF-α, via the suppression of NF-κB in hepatocytes.

[A Case of Adenocarcinoma of Duct of Luschka]

A 75-year-old man was transferred to our hospital with a diagnosis of acute cholecystitis. On next day, a laparoscopic cholecystectomy was performed. Histologic examination confirmed an adenocarcinoma arising from duct of Luschka. Patient underwent additional resection of the liver bed. No residual adenocarcinoma was seen in the surgical specimen. Adenocarcinoma of duct of Luschka is rare, but it is important during cholecystectomy to consider the presence of duct of Luschka, possibility of malignant disease and careful dissection of the gallbladder from its fossa staying close to the gallbladder wall.

Life expectancy associated with different ages at diagnosis of type 2 diabetes in high-income countries: 23 million person-years of observation

BACKGROUND

The prevalence of type 2 diabetes is increasing rapidly, particularly among younger age groups. Estimates suggest that people with diabetes die, on average, 6 years earlier than people without diabetes. We aimed to provide reliable estimates of the associations between age at diagnosis of diabetes and all-cause mortality, cause-specific mortality, and reductions in life expectancy.

METHODS

For this observational study, we conducted a combined analysis of individual-participant data from 19 high-income countries using two large-scale data sources: the Emerging Risk Factors Collaboration (96 cohorts, median baseline years 1961-2007, median latest follow-up years 1980-2013) and the UK Biobank (median baseline year 2006, median latest follow-up year 2020). We calculated age-adjusted and sex-adjusted hazard ratios (HRs) for all-cause mortality according to age at diagnosis of diabetes using data from 1 515 718 participants, in whom deaths were recorded during 23·1 million person-years of follow-up. We estimated cumulative survival by applying age-specific HRs to age-specific death rates from 2015 for the USA and the EU.

FINDINGS

For participants with diabetes, we observed a linear dose-response association between earlier age at diagnosis and higher risk of all-cause mortality compared with participants without diabetes. HRs were 2·69 (95% CI 2·43-2·97) when diagnosed at 30-39 years, 2·26 (2·08-2·45) at 40-49 years, 1·84 (1·72-1·97) at 50-59 years, 1·57 (1·47-1·67) at 60-69 years, and 1·39 (1·29-1·51) at 70 years and older. HRs per decade of earlier diagnosis were similar for men and women. Using death rates from the USA, a 50-year-old individual with diabetes died on average 14 years earlier when diagnosed aged 30 years, 10 years earlier when diagnosed aged 40 years, or 6 years earlier when diagnosed aged 50 years than an individual without diabetes. Using EU death rates, the corresponding estimates were 13, 9, or 5 years earlier.

INTERPRETATION

Every decade of earlier diagnosis of diabetes was associated with about 3-4 years of lower life expectancy, highlighting the need to develop and implement interventions that prevent or delay the onset of diabetes and to intensify the treatment of risk factors among young adults diagnosed with diabetes.

FUNDING

British Heart Foundation, Medical Research Council, National Institute for Health and Care Research, and Health Data Research UK.

Combination therapy with a sense oligonucleotide to inducible nitric oxide synthase mRNA and human soluble thrombomodulin improves survival of sepsis model rats after partial hepatectomy

ABSTRACT

Sepsis after a major hepatectomy is a critical problem. In septic shock, the inflammatory mediator, nitric oxide (NO), is overproduced in hepatocytes and macrophages. The natural antisense (AS) transcripts, non-coding RNAs, are transcribed from a gene that encodes inducible nitric oxide synthase (iNOS). iNOS AS transcripts interact with and stabilize iNOS mRNAs. A single-stranded "sense oligonucleotide" (designated as SO1) corresponding to the iNOS mRNA sequence inhibits mRNA-AS transcript interactions and reduces iNOS mRNA levels in rat hepatocytes. In contrast, recombinant human soluble thrombomodulin (rTM) treats disseminated intravascular coagulopathy by suppressing coagulation, inflammation, and apoptosis. In this study, the combination therapy of SO1 and a low dose of rTM was evaluated for hepatoprotection in a rat septic shock model after partial hepatectomy. Rats underwent 70% hepatectomy, followed by intravenous (i.v.) injection of lipopolysaccharide (LPS) after 48 h. SO1 was injected (i.v.) simultaneously with LPS, whereas rTM was injected (i.v.) 1 h before LPS injection. Similarly to our previous report, SO1 increased survival after LPS injection. When rTM, which has different mechanisms of action, was combined with SO1, it did not interfere with the effect of SO1 and showed a significant increase in survival compared to LPS alone treatment. In serum, the combined treatment decreased NO levels. In the liver, the combined treatment inhibited iNOS mRNA and protein expression. A decreased iNOS AS transcript expression by the combined treatment was also observed. The combined treatment decreased mRNA expression of the inflammatory and pro-apoptotic genes while increasing that of the anti-apoptotic gene. Furthermore, the combined treatment reduced the number of myeloperoxidase-positive cells. These results suggested that the combination of SO1 and rTM has therapeutic potential for sepsis.

Long-term complete response to lenvatinib in a patient with unresectable hepatocellular carcinoma

A 36-year-old man had been diagnosed with a solitary hepatocellular carcinoma in the right lobe of the liver by computed tomography, and right hemihepatectomy was performed 16 years previously. Approximately 13 years later, he underwent partial hepatectomy because of intrahepatic recurrence in segment 4. Multinodular intrahepatic recurrences in the remnant liver were identified 19 months after repeat hepatectomy, and he underwent transcatheter arterial chemoembolization therapy. Ultimately, six transcatheter arterial chemoembolization therapies were required because of multiple repeat multinodular intrahepatic recurrences. The patient was refractory to transcatheter arterial chemoembolization, and therefore, he participated in a trial of lenvatinib monotherapy. At lenvatinib initiation, his liver function was Child-Pugh class A. Enhanced abdominal computed tomography detected four tumors in the remnant liver. Enhanced abdominal computed tomography findings at the first evaluation showed no residual contrast uptake on arterial phase images, corresponding to a complete response according to Response Evaluation Criteria in Solid Tumors at 4 months after initiation of lenvatinib. The patient was able to continue long-term lenvatinib therapy with well-controlled general health, and he maintained a complete response for two years and three months. Here, we describe his clinical course and radiological results during lenvatinib monotherapy.

The Impact of Sorafenib in Combination with Intermittent Hepatic Arterial Infusion Chemotherapy for Unresectable Hepatocellular Carcinoma with Major Vascular Invasion

The aim of the current study was to investigate the efficacy and safety of sorafenib and intermittent hepatic arterial infusion chemotherapy with cisplatin for unresectable hepatocellular carcinoma (HCC) with severe portal vein invasion. The antitumor effect was a complete response in 1 of 38 patients, a partial response in 12 patients, stable disease in 16 patients, and progressive disease in 9 patients, for a 34.2% response rate and a 76.3% disease control rate. This regimen had favorable efficacy and acceptable safety and may be feasible for unresectable HCC with severe portal vein invasion.

Investigation of a Tumor Location-Specific Therapeutic Strategy for Intrahepatic Cholangiocarcinoma

Objective:

An optimal therapeutic strategy for intrahepatic cholangiocarcinoma (ICC) has not yet been determined. Herein we focused on intrahepatic tumor location and retrospectively analyzed tumor characteristics depending on location to elucidate a location-specific therapeutic strategy for ICC.

Methods:

Sixty-five ICC patients were divided into three groups based on the distance between the innermost portion of the tumor and portal vein branches observed on preoperative imaging: peripheral, intermediate and central ICC.

Results:

Median disease-specific survival (DSS) of the peripheral ICC was not reached, whereas median DSS was 32.9 months in intermediate ICC and 25.2 months in central ICC (p <0.05). Vascular invasion was observed in all groups (56-92%). Bile duct invasion to the first branch of the hepatic duct was more commonly observed in central ICC (43%) compared with the peripheral and intermediate ICC (0-8%). Lymph node metastasis was not observed in peripheral ICC, whereas it was frequently observed in intermediate and central ICC (39-44%). A Cox regression analysis revealed sufficient RDI (≥58.3%) of adjuvant chemotherapy (AC) significantly increased the length of DSS (HR: 0.205). Based on these data, we have proposed a location-specific therapeutic strategy as follows: peripheral ICC requires anatomical resection without lymphadenectomy; intermediate ICC requires anatomical resection with lymphadenectomy and sufficient doses of AC; and central ICC requires anatomical resection with extrahepatic bile duct resection, caudate lobectomy, lymphadenectomy, and sufficient doses of AC.

Conclusion:

We propose an intrahepatic tumor location-specific therapeutic strategy for ICC. This information could contribute to the appropriate therapeutic management of patients with ICC.

The Impact of Sorafenib in Combination with Transarterial Chemoembolization on the Outcomes of Intermediate-Stage Hepatocellular Carcinoma

Background:

We investigated the treatment outcomes and hepatic reserve of transarterial chemoembolization (TACE)-refractory patients with recurrent advanced hepatocellular carcinoma (HCC) treated with TACE plus sorafenib.

Methods:

Forty-one patients with intermediate-stage HCC defined as being TACE refractory on imaging were treated with sorafenib and TACE between 2009 and 2012 and comprised the combination treatment group. Twenty-nine patients who received repeated TACE after becoming refractory to TACE between 2005 and 2008 comprised the TACE continuation group.

Results:

Although the interval between successive rounds of TACE was significantly shorter before the patients developed TACE refractoriness, it was significantly longer after the development of TACE refractoriness, in the combination treatment group compared with the TACE continuation group. The appearance of extrahepatic spread and/or vascular invasion differed significantly between the two groups. The median overall survival was significantly longer in the combination treatment group than in the TACE continuation group (20.5 vs. 15.4 months, respectively; hazard ratio = 2.04; 95% confidence interval = 1.20–3.48). The 3-year overall survival rate was 33.4% in the combination treatment group and 3.5% in the TACE continuation group. Downstaging of the Child–Pugh class was significantly less frequent in the combination treatment group than in the TACE continuation group. In COX proportional hazards analyses, sorafenib plus TACE resulted in a better prognosis compared with repeated TACE.

Conclusions:

Treatment with sorafenib plus TACE in TACE-refractory patients with intermediate-stage HCC resulted in longer intervals between TACE rounds, better maintenance of hepatic reserve, and significantly longer OS compared with repeated TACE.

Near-Infrared Fluorescence Imaging and Photodynamic Therapy for Liver Tumors

Surgery with fluorescence equipment has improved to treat the malignant viscera, including hepatobiliary and pancreatic neoplasms. In both open and minimally invasive surgeries, optical imaging using near-infrared (NIR) fluorescence is used to assess anatomy and function in real time. Here, we review a variety of publications related to clinical applications of NIR fluorescence imaging in liver surgery. We have developed a novel nanoparticle (indocyanine green lactosome) that is biocompatible and can be used for imaging cancer tissues and also as a drug delivery system. To date, stable particles are formed in blood and have an ~10–20 h half-life. Particles labeled with a NIR fluorescent agent have been applied to cancer tissues by the enhanced permeability and retention effect in animals. Furthermore, this article reviews recent developments in photodynamic therapy with NIR fluorescence imaging, which may contribute and accelerate the innovative treatments for liver tumors.

New Hepatic Resection Criteria for Intermediate-Stage Hepatocellular Carcinoma Can Improve Long-Term Survival: A Retrospective, Multicenter Collaborative Study

BACKGROUND

Hepatic resection (HR) is not recommended for intermediate-stage hepatocellular carcinoma (HCC) by the Barcelona Clinic Liver Cancer criteria. We examined the prognostic factors of HR for intermediate-stage HCC and developed new HR criteria for intermediate-stage HCC.

METHODS

A total of 110 patients who underwent HR without any prior treatment for intermediate-stage HCC between January 2007 and December 2012 were enrolled at eight university hospitals. The outcomes and prognostic factors of HR were evaluated to develop new HR criteria.

RESULTS

In terms of tumor size and number, the most significant prognostic factors were within the up-to-seven criteria. Furthermore, serum albumin level ≥35 g/L and serum alpha-fetoprotein (AFP) level.

Mortality analysis of Aeromonas hydrophila infection in hepato-biliary pancreatic surgery: Multicenter retrospective observational study

BACKGROUND/PURPOSE

Aeromonas hydrophila can cause lethal infectious complications after surgery. There have been no large cohort studies of this specific to the hepato-biliary-pancreatic (HBP) field. We investigate the postoperative influence of A hydrophila infection after HBP surgery.

METHODS

We retrospectively reviewed patients who underwent HBP surgery between 2008 and 2017 at eight university hospitals. Patients with A hydrophila isolation during perioperative management were extracted, and their postoperative courses were investigated.

RESULTS

Bacterial culture examination of 10 074 patients was performed as perioperative management. Among them, 76 patients (0.75%) had A hydrophila isolation, most of whom underwent pancreatoduodenectomy (n = 38) or hepatectomy with biliary reconstruction (n = 14). There were seven mortalities after these two procedures (13.5%), five within 3 days after the onset of infection. Bile (n = 48) and abdominal drainage fluid (n = 29) were major sites of A hydrophila isolation. Typical prophylactic antibiotics, cefazolin or flomoxef, were mostly resistant. There was no mortality among patients that received sensitive antibiotics prophylactically.

CONCLUSIONS

Isolation of A hydrophila was low in our cases of HBP surgery, but the condition of some patients deteriorated rapidly by this infection. Although there could be several bacterial infections during management of HBP surgery, A hydrophila should not be overlooked. Preparation of appropriate prophylactic antibiotics may prevent or reduce mortality.

The Proton Pump Inhibitor Lansoprazole Has Hepatoprotective Effects in In Vitro and In Vivo Rat Models of Acute Liver Injury

BACKGROUND/AIMS

The proton pump inhibitor lansoprazole (LPZ) is clinically used to reduce gastric acid secretion, but little is known about its possible hepatoprotective effects. This study aimed to investigate the hepatoprotective effects of LPZ and its potential mechanisms using in vitro and in vivo rat models of liver injury.

METHODS

For the in vitro model of liver injury, primary cultured rat hepatocytes were treated with interleukin-1β in the presence or absence of LPZ. The influence of LPZ on inducible nitric oxide synthase (iNOS) induction and nitric oxide (NO) production and on the associated signaling pathways was analyzed. For the in vivo model, rats were treated with D-galactosamine (GalN) and lipopolysaccharide (LPS). The effects of LPZ on survival and proinflammatory mediator expression (including iNOS and tumor necrosis factor-α) in these rats were examined.

RESULTS

LPZ inhibited iNOS induction partially through suppression of the nuclear factor-kappa B signaling pathway in hepatocytes, thereby reducing potential liver injury from excessive NO levels. Additionally, LPZ increased survival by 50% and decreased iNOS, tumor necrosis factor-α, and cytokine-induced neutrophil chemoattractant-1 mRNA expression in the livers of GalN/LPS-treated rats. LPZ also inhibited nuclear factor-kappa B activation by GalN/LPS.

CONCLUSIONS

LPZ inhibits the induction of several inflammatory mediators (including cytokines, chemokines, and NO) partially through suppression of nuclear factor-kappa B, resulting in the prevention of fulminant liver failure. The therapeutic potential of LPZ for liver injuries warrants further investigation.

Laparoscopic versus open liver resection for hepatocellular carcinoma in elderly patients: a multi-centre propensity score-based analysis

BACKGROUND

The frequency of liver resection in elderly patients has been increasing. However, data are limited regarding the safety of laparoscopic liver resection (LLR) compared with that of open liver resection (OLR) for hepatocellular carcinoma (HCC) in elderly patients. The present study aimed to compare short-term outcomes between LLR and OLR in elderly patients with HCC using propensity score matching.

METHODS

The study included 630 patients (age, ≥ 75 years) who underwent liver resection for HCC at nine liver centres between April 2010 and December 2017. Patients were divided into LLR and OLR groups, and perioperative outcomes were compared between the groups. In addition, subgroup analysis was performed according to age (75-79 and ≥ 80 years).

RESULTS

Of the 630 patients, 221 and 409 were included in the LLR and OLR groups, respectively. After propensity score matching, 155 patients were included in each group. Intraoperative blood loss and the transfusion, post-operative overall complication and major complication rates were lower in the matched LLR than the matched OLR group (P < 0.001, P = 0.004, P < 0.001 and P < 0.001, respectively). Moreover, post-operative pulmonary and cardiovascular complications were less frequent in the matched LLR group (P = 0.008 and P = 0.014, respectively). In subgroup analysis, among octogenarians, the post-operative major complication rate was lower and hospital stay was shorter in the matched LLR than the matched OLR group (P < 0.001 and P < 0.001, respectively).

CONCLUSION

LLR for HCC is associated with good short-term outcomes in patients aged ≥ 75 years compared with OLR. LLR is safe and feasible in selected octogenarians with HCC.

Glutathione inhibits expression of the proinflammatory biomarker inducible nitric oxide synthase in hepatocytes

Background: Intracellular glutathione (GSH) plays an important regulatory role in the host response to liver injury. However, there have been few scientific reports on the anti-inflammatory effects of GSH. In the inflamed liver, proinflammatory cytokines stimulate liver cells, followed by expression of inducible nitric oxide synthase (iNOS). Excessive nitric oxide (NO) levels produced by iNOS are one of the factors involved in liver injury. Therefore, inhibiting iNOS induction is important for preventing liver injury. This study aimed to investigate the protective effects of GSH on the liver by examining interleukin (IL)-1β-stimulated hepatocytes.Methods: Primary cultured rat hepatocytes were treated with IL-1β in the presence or absence of GSH. Induction of iNOS and its signaling pathway were analyzed.Results: Addition of GSH decreased IL-1β-induced iNOS protein and mRNA expression levels, which resulted in inhibition of NO production. GSH also decreased tumor necrosis factor (TNF)-α and IL-6 mRNA expression. GSH blocked “type I IL-1 receptor upregulation”, one of the essential signaling pathways for iNOS induction, through inactivation of an upstream kinase, phosphatidylinositol 3-kinase/Akt. In contrast, GSH had no effects on degradation of IκB and activation of NF-ĸB (nuclear translocation and its DNA binding). Transfection experiments revealed that GSH reduced iNOS mRNA levels at the promoter transactivation and mRNA stabilization steps. Delayed administration of GSH after IL-1β addition also inhibited iNOS induction. Conclusions: Our study suggests that GSH affects induction of inflammatory mediators, including iNOS and TNF-α, indicating its therapeutic potential for organ injuries, especially for the liver.Keywords: glutathione, inducible nitric oxide synthase, liver injury, primary cultured hepatocytes, type I interleukin-1 receptor, tumor necrosis factor-α

Resection for Primary Retroperitoneal Serous Adenocarcinoma and Liver Metastasis

Primary retroperitoneal serous adenocarcinoma (PRSA) is a rare malignancy of which only seven cases have been reported in the literature. The clinical features and outcomes of PRSA are not well understood. We herein report a case of PRSA with liver metastasis in a 74-year-old woman who was treated with surgical excision. The tumor cells were positive for estrogen receptor, Wilms tumor 1, PAX8, p53, and cytokeratin AE1/AE3. The final diagnosis was PRSA and liver metastasis. The pathological features of PRSA resemble those of ovarian serous carcinoma, which suggests that a combination of surgical excision with adjuvant chemotherapy may be the best option.

Hepatectomy in a case of hepatocellular carcinoma with constitutional indocyanine green excretory defect

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Constitutional indocyanine green excretory defect is extremely rare.

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The ICGR15 is important for estimating hepatic functional reserve and selection of the appropriate surgical procedure.

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Because of the rarity of constitutional ICG excretory defect, its clinical features are not well understood.

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At present, the indications for surgery for this condition should be comprehensively considered.

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Findings of liver function tests, such as a general liver function test and GSA liver scintigraphy, are important for treating this disorder.

Introduction: Constitutional indocyanine green (ICG) excretory defect is extremely rare. The indocyanine green retention rate at15 min (ICGR15) is important for estimating hepatic functional reserve and selection of the appropriate surgical procedure before hepatectomy is performed. Because of the rarity of constitutional ICG excretory defect, its clinical features are not well understood. We report here evaluation and treatment of a patient with such a disorder.

Presentation of case: An 83-year-old man was admitted to hospital with the diagnosis of resectable hepatocellular carcinoma. The preoperative indocyanine green (ICG) retention rate at 15 min was greater than 76.2%. Despite this finding, Child–Pugh classification and ^99mTc-galactosyl human serum albumin (GSA) liver scintigraphy didn’t show any abnormal findings, and there was no background disease. Therefore, we diagnosed him with constitutional ICG excretory defect and performed partial hepatectomy. For patients requiring hepatectomy with this disease the indications and procedure for surgery should be considered. These should be based on liver function tests such as GSA liver scintigraphy.

Conclusions: Constitutional ICG excretory defect is an extremely rare disorder. At present, the indications for surgery for this condition should be comprehensively considered. Findings of liver function tests, such as a general liver function test and GSA liver scintigraphy, are important for treating this disorder.

Loss of skeletal muscle mass in patients with chronic liver disease is related to decrease in bone mineral density and exercise tolerance

AIM

This study aimed to identify the relationship between loss of skeletal muscle mass and clinical factors such as osteoporosis in patients with chronic liver disease.

METHODS

The subjects were 112 patients (85 men and 27 women) with hepatocellular carcinoma who were scheduled to undergo hepatectomy. Skeletal muscle reduction was diagnosed according to the cut-off level of the skeletal mass index (SMI) for Asians (men <7.0 kg/m² , women <5.4 kg/m² ). Osteoporosis was diagnosed according to T-score ≤-2.5 standard deviation. The SMI and T-score were assessed using the results of dual-energy X-ray absorption. Peak oxygen consumption (PeakVO₂ ), an index of exercise tolerance, was evaluated using the cardiopulmonary exercise test. The characteristics of patients with low SMI (low SMI group) were compared with those of patients whose SMI was not low (control group). Outcomes are presented as median (interquartile range).

RESULTS

The T-score was significantly lower in the low SMI group (control vs. low SMI -1.1 [1.8] vs. -1.6 [1.9], P = 0.049). T-score positively correlated with SMI (r = 0.409, P < 0.0001). PeakVO₂ was significantly decreased in the low SMI group (17.7 [6.3] vs. 14.4 [4.5], P = 0.006). In multivariate logistic regression analysis, T-score (odds ratio [OR], 3.508; 95% confidence interval [CI], 1.074-11.456; P = 0.038) and PeakVO₂ (OR, 3.512; 95% CI, 1.114-11.066; P = 0.032) were significantly related to SMI, independent of age and sex.

CONCLUSIONS

Skeletal muscle reduction in chronic liver disease is closely related to exercise tolerance and osteoporosis, and these factors are believed to be associated with physical inactivity in daily life.

Metformin inhibits expression of the proinflammatory biomarker inducible nitric oxide synthase in hepatocytes

Background: Metformin is used to treat patients with type II diabetes. However, there are few scientific reports on its anti-inflammatory effects. In the inflamed liver, proinflammatory cytokines stimulate liver cells, followed by inducible nitric oxide synthase (iNOS) expression. Excessive NO levels produced by iNOS have been implicated as a factor in liver injury. As a result, it is essential to inhibit iNOS induction to prevent liver injury.Objective: This study aimed to investigate liver protective effects of metformin by examining interleukin (IL)-1β-stimulated hepatocytes. Methods: Primary cultured rat hepatocytes were treated with interleukin (IL)-1β in the presence or absence of metformin. iNOS induction and its signaling pathway were analyzed.Results: Metformin decreased iNOS protein and mRNA expression, resulting in the inhibition of hepatic NO production. Metformin also reduced tumor necrosis factor (TNF)-α and IL-6 mRNA expression. Metformin inhibited an essential signaling pathway for iNOS induction, type I IL-1 receptor upregulation. Transfection experiments revealed that metformin reduced iNOS mRNA levels through both promoter transactivation and mRNA stabilization. Delayed metformin administration after IL-1β addition also inhibited iNOS induction. Conclusions: Metformin affects the induction of inflammatory mediators including iNOS and TNF-α, demonstrating its therapeutic potential for organ injuries, including the liver.Keywords: metformin, inducible nitric oxide synthase, liver injury, primary cultured hepatocytes, type I interleukin-1 receptor, tumor necrosis factor-α 

Increased FGF19 copy number is frequently detected in hepatocellular carcinoma with a complete response after sorafenib treatment

The multi-kinase inhibitor sorafenib is clinically approved for the treatment of patients with advanced hepatocellular carcinoma (HCC). We previously reported that fibroblast growth factor 3 and 4 (FGF3/FGF4) amplification is a predictor of a response to sorafenib. This study aims to analyze the relationship between FGF-FGF receptor (FGFR) genetic alterations and the response to sorafenib. Formalin-fixed, paraffin-embedded tissue specimens from HCC patients who had achieved a complete response (CR, N=6) or non-CR (N=39) to sorafenib were collected and were examined for FGF-FGFR gene alterations using next generation sequencing and copy number assay. FGFR mutations were detected in 5 of 45 (11.1%) cases. There was no significant association between FGFR mutation status and the response to sorafenib. We detected no increase in the FGF3/FGF4 copy number in CR cases. An FGF19 copy number gain was detected more frequently among CR cases (2/6, 33.3%) than among non-CR cases (2/39, 5.1%) (P = 0.024, Chi-squared test). In conclusion, a copy number gain for FGF19 may be a predictor of a response to sorafenib, in addition to FGF3/FGF4 amplification.

Ratio of mean platelet volume to platelet count is a potential surrogate marker predicting liver cirrhosis

AIM

To provide a simple surrogate marker predictive of liver cirrhosis (LC).

METHODS

Specimens from 302 patients who underwent resection for hepatocellular carcinoma between January 2006 and December 2012 were retrospectively analyzed. Based on pathologic findings, patients were divided into groups based on whether or not they had LC. Parameters associated with hepatic functional reserve were compared in these two groups using Mann-Whitney U-test for univariate analysis. Factors differing significantly in univariate analyses were entered into multivariate logistic regression analysis.

RESULTS

There were significant differences between the LC group (n = 100) and non-LC group (n = 202) in prothrombin activity, concentrations of alanine aminotransferase, aspartate aminotransferase, total bilirubin, albumin, cholinesterase, type IV collagen, hyaluronic acid, indocyanine green retention rate at 15 min, maximal removal rate of technitium-99m diethylene triamine penta-acetic acid-galactosyl human serum albumin and ratio of mean platelet volume to platelet count (MPV/PLT). Multivariate analysis showed that prothrombin activity, concentrations of alanine aminotransferase, aspartate aminotransferase, total bilirubin and hyaluronic acid, and MPV/PLT ratio were factors independently predictive of LC. The area under the curve value for MPV/PLT was 0.78, with a 0.8 cutoff value having a sensitivity of 65% and a specificity of 78%.

CONCLUSION

The MPV/PLT ratio, which can be determined simply from the complete blood count, may be a simple surrogate marker predicting LC.

Curcumin protects liver inflammation by suppressing expression of inducible nitric oxide synthase in primary cultured rat hepatocytes

Background: Curcumin has beneficial effects on organ metabolism. However, there is little evidence that curcumin affects inflammatory mediators, such as tumor necrosis factor (TNF)-α and nitric oxide (NO). In an inflamed liver, proinflammatory cytokines stimulate liver cells, followed by the induction of inducible NO synthase (iNOS). Excessive NO produced by iNOS is one of the factors in liver injury. Therefore, inhibiting iNOS induction for preventing liver injury is important.Objective: This study aimed to investigate liver protective effects of curcumin by examining interleukin (IL)-1β-stimulated hepatocytes.Methods: Primary cultured rat hepatocytes were treated with IL-1β in the presence or absence of curcumin. Induction of NO production and iNOS, and the signaling pathway of iNOS were analyzed.Results: Simultaneous addition of IL-1β and curcumin decreased expression levels of iNOS protein and mRNA, resulting in inhibition of NO production. Curcumin also reduced mRNA expression of TNF-α and IL-6. Curcumin inhibited two essential signaling pathways for iNOS induction, NF-κB activation and type I IL-1 receptor upregulation. Transfection experiments revealed that curcumin reduced iNOS mRNA levels at the promoter activation and mRNA stabilization steps. Delayed administration of curcumin after IL-1β addition also inhibited iNOS induction.Conclusions: Curcumin affects induction of inflammatory mediators, such as iNOS and TNF-α, in part through the inhibition of NF-κB activation in hepatocytes. Curcumin may have therapeutic potential for organ injuries, including the liver.Key words: curcumin, inducible nitric oxide synthase, liver injury, primary cultured hepatocytes, nuclear factor-κB, type I interleukin-1 receptor, tumor necrosis factor-α. 

Combination therapies for primary hepatic neuroendocrine carcinoma: a case report

Background

Primary hepatic neuroendocrine carcinomas are extremely rare. Because of the rarity of PHNEC, its clinical features and treatment outcomes are not well understood. A proper diagnosis and the correct therapeutic approach therefore remain clinically challenging.

Case presentation

A 67-year-old man was admitted to our department because of a liver tumor. Computed tomography revealed a single liver tumor 50 mm in diameter and located in the S3 region. Biopsy and imaging findings resulted in a diagnosis of primary hepatic neuroendocrine carcinoma. Left lateral segmentectomy was performed. Immunohistochemically, the tumor cells were positive for synaptophysin, chromogranin A, and CD56. Ki-67 was positive in > 90% of the tumor cells. The final diagnosis was primary hepatic neuroendocrine carcinoma. The patient suffered two episodes of lymph node recurrence. Nonetheless, the tumor was excised to prolong survival. Thus, after lymphadenectomy, he received adjuvant chemotherapy for 6 months. Two years after surgery, the patient remains alive and in good general condition.

Conclusions

In most cases, primary hepatic neuroendocrine carcinoma, while extremely rare, has a poor prognosis. At present, surgical resection is a priority for curative treatment, but in patients with recurrence, combined therapies are recommended.

Skipping breakfast and 5-year changes in body mass index and waist circumference in Japanese men and women

OBJECTIVE

This study investigated the relationship between frequency of skipping breakfast and annual changes in body mass index (BMI) and waist circumference (WC).

METHODS

The participants were 4,430 factory employees. BMI and WC were measured repeatedly at annual medical examinations over a 5-year period. The association between frequency of skipping breakfast at the baseline examination and annual changes in anthropometric indices was evaluated using the generalized estimating equation method.

RESULTS

The mean (standard deviation) BMI was 23.3 (3.0) kg m^-2 for men and 21.9 (3.6) kg m^-2 for women; and the mean WC was 82.6 (8.7) cm for men and 77.8 (9.8) cm for women. During the follow-up period, mean BMI increased by 0.2 kg m^-2 for men and women, and mean WC increased by 1.1 cm for men and 1.0 cm for women. The annual change in the BMI of men who skipped breakfast four to six times per week was 0.061 kg m^-2 higher, and that of those who skipped breakfast seven times per week was 0.046 kg m^-2 higher, compared with those who did not skip breakfast. Annual changes in the WC of male participants who skipped breakfast seven times per week was 0.248 cm higher than that of those who did not skip breakfast. Skipping breakfast was not associated with changes in BMI or WC in women.

CONCLUSIONS

Skipping breakfast was closely associated with annual changes in BMI and WC among men, and eating breakfast more than four times per week may prevent the excessive body weight gain associated with skipping breakfast.

Genipin Inhibits the Induction of Inducible Nitric Oxide Synthase Through the Inhibition of NF-κB Activation in Rat Hepatocytes

BACKGROUND/AIMS

Genipin is a component of Japanese traditional herbal medicine (Kampo), inchinkoto, and is used for the treatment of various liver injuries. However, there are few scientific evidence for its anti-inflammatory effects and mechanisms. In inflamed liver, proinflammatory cytokines including tumor necrosis factor (TNF)-α and interleukin (IL)-1β stimulate liver cells, followed by the expression of inducible nitric oxide synthase (iNOS). Excessive levels of NO produced by iNOS have been implicated as one of the factors in liver injury. Thus it is essential to inhibit iNOS induction for the prevention of liver injury. In this study, we examined IL-1β-stimulated hepatocytes as a simple "in vitro liver injury model" to investigate liver protective effects of genipin.

METHODS

Primary cultured rat hepatocytes were treated with IL-1β in the presence or absence of genipin. The induction of NO production and iNOS, and its signaling pathway were analyzed.

RESULTS

In IL-1β-stimulated hepatocytes, genipin inhibited the production of NO dose- and timedependently, and reduced the levels of iNOS protein and its mRNA expression. Genipin also reduced mRNA expressions of TNF-α and IL-6. Genipin inhibited two essential signaling pathways for iNOS induction, IκB degradation/NF-κB activation and type I IL-1 receptor upregulation. Transfection experiments revealed that genipin decreased the expression of iNOS mRNA through both inhibitions of the promoter activation and mRNA stabilization. Delayed administration of genipin after IL-1β addition also inhibited iNOS induction.

CONCLUSION

Genipin influenced the induction of inflammatory mediators, iNOS and TNF-α, in part through the inhibition of NF-κB activation in hepatocytes. Genipin may have therapeutic potential for organ injuries including liver.

Protective effects of active hexose correlated compound in a rat model of liver injury after hepatectomy

Background: Recent evidence has indicated that a functional food, active hexose correlated compound (AHCC), has liver-protective effects via suppression of inflammatory mediators, such as inducible nitric oxide synthase (iNOS) and tumor necrosis factor (TNF)-α.Objective: This study aimed to investigate whether AHCC has beneficial effects in a rat model of endotoxin-induced liver injury after partial hepatectomy, in addition to clarifying the mechanisms of action of AHCC.Methods: Rats were treated with 70% of partial hepatectomy and lipopolysaccharide (PH/LPS) to induce acute liver injury. A normal diet with or without 2% AHCC was administered orally 10 days before 70% hepatectomy. Inflammatory mediators were analyzed.Results: AHCC improved the survival rate by 70% in PH/LPS rats. AHCC prevented an increase in serum transaminase levels, and histopathological changes and apoptosis in the liver. AHCC reduced iNOS mRNA and protein expression in the liver, resulting in inhibition of nitric oxide production. AHCC also reduced TNF-α, cytokine-induced neutrophil chemoattractant-1, and interleukin-6 mRNA expression, but enhanced expression of interleukin-10. An electrophoretic mobility shift assay with hepatic nuclear extracts demonstrated that AHCC reduced the activation of nuclear factor (NF)-κB induced by PH/LPS treatment.Conclusion: AHCC inhibits induction of inflammatory mediators, including iNOS and TNF-α, in part through inhibition of NF-κB activation in a rat model of liver injury. Our findings suggest that AHCC prevents postoperative liver failure after liver resection.Keywords: active hexose correlated compound, inducible nitric oxide synthase, liver injury, nuclear factor-κB, tumor necrosis factor-α

Assessing the feasibility of clinicopathological features of hepatic resection for hepatocellular carcinoma in patients over 80 years of age

The aim of the present study was to evaluate the clinicopathological features, benefits and problems associated with hepatic resection of hepatocellular carcinoma in patients aged ≥80 years. Between 2006 and 2013, hepatic resection was performed in 395 hepatocellular carcinoma patients, including 351 patients aged <80 years and 44 patients aged ≥80 years. Clinicopathological examination revealed that the tumor size was significantly larger among patients of ≥80 years of age. However, recurrence-free and cumulative survival rates were similar between the two age groups. The occurrence of post-operative complications was an independent risk factor for survival among patients ≥80 years of age. In addition, the albumin level was identified as a risk factor for post-operative complications. The post-operative transition towards an improvement in the albumin level in the ≥80 years group was significantly lower compared with the <80 years group. It was revealed that hepatic resection was feasible for elderly patients. However, the post-operative improvement in the albumin levels was less marked among patients ≥80 years of age, and lower albumin levels were associated with post-operative complications and prognosis. Therefore, elderly patients undergoing hepatic resection should receive peri-operative management including special nutrition.

Evaluation of fluorescence imaging with indocyanine green in hepatocellular carcinoma

Background

We hypothesized that indocyanine green (ICG) fluorescence patterns using Clairvivo OPT in resected liver specimens could confirm hepatocellular carcinoma (HCC) better than earlier commercial imaging systems. This preclinical trial evaluated the effectiveness of fluorescence imaging as an intraoperative cancer navigation tool.

Methods

ICG fluorescence images of resected specimens from 190 patients with HCC were classified into two groups according to whether high fluorescence was seen in the HCC (high cancerous [HC] group) or in the surrounding liver tissue (high surrounding [HS] group). The HC and HS groups were sub-classified into whole and partial types and whole and ring types, respectively.

Results

The HC group had significantly higher prevalence of esophageal or gastric varices, and worse liver function than patients in the HS group. The HC group also had a higher percentage of limited resection cases than did the HS group. Cirrhotic liver histology was significantly more common in the HC group than in the HS group. Multivariate analysis revealed that the HC group was a predictive factor for cirrhosis in HCC patients. Among the HC patients, a higher percentage of well-differentiated HCC cases were seen in the partial-type subgroup than in the whole-type subgroup (23/48 (48 %) vs. 7/68 (10 %)). In the HS group, the ring-type subgroup had a higher percentage of poorly differentiated HCC cases than did the whole-type subgroup (6/37 (16 %) vs. 0/37 (0 %)).

Conclusion

Tumor differentiation and fibrosis in the non-cancerous liver parenchyma could affect ICG fluorescence imaging in HCC. ICG fluorescence imaging may be a good indication for fibrosis stage. In future, we will try to evaluate fluorescence imaging with ICG for intraoperative cancer navigation in HCC, using a portable near-infrared fluorescence imaging system.

Intraoperative Detection of Superficial Liver Tumors by Fluorescence Imaging Using Indocyanine Green and 5-aminolevulinic Acid

BACKGROUND/AIM

Indocyanine green (ICG) and the porphyrin precursor 5-aminolevulinic acid (5-ALA) have been approved as fluorescence imaging agents in the clinical setting. This study evaluated the usefulness of fluorescence imaging with both ICG and 5-ALA for intraoperative identification of latent small liver tumors.

PATIENTS AND METHODS

There were 48 patients who had main tumors within 5 mm of the liver surface. 5-ALA hydrochloride was orally administered to patients 3 h before surgery. ICG had been intravenously injected within 14 days prior to surgery. Intraoperatively, after visual inspection, manual palpation and ultrasonography fluorescence images of the liver surface were obtained with ICG and 5-ALA prior to resection.

RESULTS

With ICG, the sensitivity, specificity and accuracy for detecting the preoperatively identified main tumors were 96%, 50% and 94%, respectively. Twelve latent small tumors were newly detected on the liver surface using ICG, five of which proved to be carcinomas. With 5-ALA, the sensitivity, specificity and accuracy for detecting the main tumors were 57%, 100% and 58%, respectively. Five latent small tumors were newly detected using 5-ALA; all were carcinomas. Overall, five new tumors were detected by both ICG and 5-ALA fluorescence imaging; two were hepatocellular carcinomas (HCCs) and three were metastases of colorectal cancer. The sensitivity and specificity of ICG fluorescence imaging for main tumor detection were relatively high and low, respectively, but the opposite was true of 5-ALA imaging.

CONCLUSION

Fluorescence imaging using 5-ALA may provide greater specificity in the detection of surface-invisible malignant liver tumors than using ICG fluorescence imaging alone.

Histological tumor regression after preoperative chemotherapy for colorectal liver metastases: Correlations with radiological response and prognosis

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Background: The purpose of this study was to characterize histological tumor regression grade (TRG) to colorectal liver metastases (CLM) treated with preoperative chemotherapy followed by liver surgery, and to evaluate whether TRG correlates with radiological response and prognosis. Methods: This study included 30 patients with CLM treated by surgical resection after preoperative chemotherapy with oxaliplatin- or irrinotecan-based regimens with or without molecular target agents. TRG was determined by the amount of fibrosis and necrosis replaced from tumor cells, ranging TRG 0 (0%), 1 (1-24%), 2 (25-50%), 3 (51-99%), and 4 (100%). Results: TRG 0, 1, 2, 3, and 4 were observed in 0%, 6.7%, 10.0%, 66.7%, and 16.6% of the patients, respectively. There were no relations between TRG and regimen, including molecular target agents. As shown in the table, radiological response was not significantly correlated with TRG. Patients with histological major response (TRG 3+4) had better prognosis (MST; TRG 1+2 vs. 3+4: 20.0 vs. 50 months, P= 0.007), and a multivariate analysis identified histological major response as an independent good prognostic factor. Conclusions: In this analysis, histological TRG predicted survival after preoperative chemotherapy and resection for CLM. Preoperative radiological response could not evaluate TRG. [Table: see text]

Effect of Intramuscular Adipose Tissue Content on Prognosis in Patients Undergoing Hepatocellular Carcinoma Resection

BACKGROUND

It has recently been reported that myosteatosis, the infiltration of fat in skeletal muscle, is associated with insulin resistance and type 2 diabetes mellitus. The present study investigated the effect of skeletal muscle fat accumulation on short- and long-term outcomes following partial hepatectomy for hepatocellular carcinoma (HCC) and aimed to identify prognostic factors.

METHODS

The records of 141 HCC patients who underwent hepatectomy were retrospectively reviewed. Clinicopathological and outcome data from 71 patients with high intramuscular adipose tissue content (IMAC) were compared with those from 70 patients with low IMAC.

RESULTS

The 5-year overall survival rate was 46% among patients with high IMAC and 75% among those with low IMAC. The 5-year disease-free survival rates in these groups were 18 and 38%, respectively. Multivariate analysis revealed that high IMAC was predictive of an unfavorable prognosis. High IMAC was significantly correlated with liver dysfunction, higher intraoperative blood loss, the need for blood transfusion, and comorbid diabetes mellitus.

CONCLUSIONS

Greater fat accumulation in skeletal muscle was predictive of worse overall survival after partial hepatectomy in patients with HCC, even with adjustment for other known predictors. The identification of patients with greater skeletal muscle fat accumulation before hepatectomy could permit early preventive strategies to maintain muscle quality and thus improve prognosis and patient selection for hepatectomy.

[OBJECTIVE ASSESSMENT OF POSTOPERATIVE PAIN AFTER DIGESTIVE TRACT SURGERY]

Pain is a sensation associated with subjective factors, making it difficult to measure and assess. Currently, there is no widely accepted method of objectively assessing pain, and therefore subjective assessments such as the Visual Analogue Scale (VAS) are generally used. The PainVision system has been developed for the quantitative analysis of pain and comparison of postoperative pain intensity. In this study, we investigated whether postoperative pain could be objectively assessed using this system in digestive tract surgery patients. Pain scores were measured with the VAS, the PainVision system, and the short-form McGill Pain Questionnaire in patients undergoing open or laparoscopic hepatectomy, open or laparoscopic gastrectomy, and laparoscopic cholecystectomy. As measured using the PainVision system, postoperative pain intensity was lower in patients who underwent laparoscopic surgery compared with open hepatectomy. In open hepatectomy patients, pain intensity measured by the PainVision system was significantly lower on postoperative days (POD) 7 and 10 than on POD 1. Preemptive use of nonsteroidal antiinflammatory drugs significantly reduced postoperative pain in open hepatectomy patients. The results showed that PainVision effectively quantifies pain intensity after digestive tract surgery. Objective assessment of postoperative pain may lead to earlier mobility and improved quality of life.