Recently we have been performing S4a + S5 with total resection of the caudate lobe (S1) by using a dome-like dissection along the root of the middle hepatic vein at the pinnacle, which we refer to as the Taj Mahal liver parenchymal resection, for carcinoma of the biliary tract. This procedure offers the following advantages: (1) It allows total resection of the caudate lobe, including the paracaval portion (S9), and (2) because the cut surface of the liver is large, it allows intrahepatic jejunostomy to be performed more easily with a good field of view. The indications for this procedure include hilar bile duct carcinoma, gallbladder carcinoma, and choledochal cyst (type IVA). Because of the high rate of hilar liver parenchyma and caudate lobe invasion associated with hilar bile duct carcinoma, the liver must be resected. The Taj Mahal procedure is indicated in cases where extended liver resection is impossible. The dissection limits of this procedure are, on the left side, the B2+3 bifurcation at the right margin of the umbilical portion of the portal vein and, on the right side, the B8 of the anterior branch and the B6+7 bifurcation of the right posterior branch. This procedure could also be described as a reduced form of extended right hepatectomy and extended left hepatectomy. For gallbladder carcinoma, this procedure is indicated to ensure an adequate surgical margin and eradicate transvenous liver metastasis, particularly in cases of pT2 lesions. Hilar and caudate lobe invasion also occurs in liver bed-type gallbladder carcinoma, and bile duct resection and caudate lobe resection are required for the surgery to be curative. We performed this procedure in four cases of hilar bile duct carcinoma, five cases of gallbladder carcinoma, and one case each of choledochal cyst (type IVA) with carcinoma of the bile duct and gallbladder adenomyomatosis. Curative resection was possible in all except the patient with adenomyomatosis, and all of the patients are alive and recurrence free 10 to 37 months postoperatively. This procedure, in addition to preserving liver function, provides a wide field of view and facilitates reconstruction of multiple intrahepatic bile ducts. Thus it can be said to be a curative operation not only in patients considered high risk but also in those whose hilar bile duct carcinoma is limited to the bifurcation area (Bismuth type IIIa and IIIb) and in gallbladder carcinoma up to pT2 with slight extension on the hepatic side.

Adenomyoma↗

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A new classification of cystic malignant tumours of the liver: classification of 65 cases reported at the 26th annual meeting of the Liver Cancer Society of Japan.

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Adenocarcinoma↗

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A case report of arterial emboli in a male secondary to idiopathic hypertrophic subaortic stenosis.

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Adult↗

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Behavioral effect of herbal glycoside in the forced swimming test.

We investigated the behavioral effects of Chinese herbal medicines in the forced swimming test. One of these medicines, Kami-shoyo-san, induced an antidepressive climbing behavior in mice. An effective substance detected to be an O-linked glycoside with the sugar chain structure GalNAc alpha 1-3GalNAc was separated. The behavioral effect was dose-dependently decreased by the dopamine 2 antagonist sulpiride, but not by the dopamine 1 antagonist SCH-233960. Investigated Chinese herbal medicines, including Kami-shoyo-san, have been used for human depression. These facts suggest that glycoside is one of the antidepressant-like substances of Chinese herbal medicines.

Animals↗

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Analysis of microsatellite instability, TGF-beta type II receptor gene mutations and hMSH2 and hMLH1 allele losses in pancreaticobiliary maljunction-associated biliary tract tumors.

While pancreaticobiliary maljunctions (PBM) are clearly associated with biliary tract tumor development, little is known about their molecular mechanisms. This study was conducted to assess the contributions of microsatellite instability (MSI), mutations of transforming growth factor type II receptor (TGF-beta RII) and insulin-like growth factor type II receptor (IGF RII) genes and loss of heterozygosity (LOH) of hMSH2 and hMLH1 in 23 biliary tract tumors using PCR methods. MSI was detected by 13 markers in 16/23 samples (69.6%). TGF-beta RII mutations were detected in eight of these (50%), and of the IGF IIR gene in two (12.5%). LOH was detected in 4/16 (25%) at the hMSH2 locus, and 2/16 (12.5%) at the hMLH1 locus. No TGF-beta RII mutations or LOH of hMSH2 and hMLH1 were detected in MSI-negative samples. These findings suggest that MSI plays an important role in carcinogenesis of the biliary tract epithelium with PBM cases.

Adaptor Proteins, Signal Transducing↗

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Surgical anatomy of the medial segment (S4) of the liver with special reference to bile ducts and vessels.

BACKGROUND/AIMS: Resection of the inferior area of the medial segment (S4a) plus S5 with preservation of the superior area of the medial segment (S4b) is being performed to manage hilar bile duct carcinoma and pT2 type gallbladder carcinoma, and thus, attention has been focused on the surgical anatomy of the medial segment of the liver to identify the specific vessels and bile ducts of the areas of that segment to be resected and to be preserved. METHODOLOGY: Anatomical study of the bile duct, portal vein, middle hepatic vein, and middle hepatic artery to the medial segment branches of the liver (S4) was performed in a total of 171 specimens comprised of 71 adult cadavers, and 100 liver casts. RESULTS: 1) Two main types of bile duct branches of the medial segment (B4) were recognized. Type I included the branches which joined to the left hepatic duct on the hilar duct side (35.5%), and type II included the branches that joined on the peripheral side (54.6%). Several subtypes were also found in both types. The B2-B3 confluence was mostly on the left (41.7%) or posterior (42.7%) to the umbilical portion (UP) of the portal vein, and to the right of the UP (hilar side) in only 15.6%. 2) The portal vein of the medial segment branches (P4): P4a branched from the right angle and upper right border of the UP in every specimen. The most common morphology was 1 large and 2-3 small branches (41%). P4b was almost always found to branch posterior to the UP and lower than P4a, and the most common morphology was 1 large and 0-1 small branches (57.8%). 3) The middle hepatic vein: In 83.2% a common trunk was observed at the confluence with the inferior vena cava, and 8 types of the middle hepatic vein were recognized. 4) The middle hepatic artery: It arose from the left hepatic artery in 61.5%, from of the right hepatic artery in 27.5%, from the proper hepatic artery in 5.5%, and from both the left and the right hepatic artery in 5.5%. CONCLUSIONS: The detailed vascular and bile duct anatomy of S4 is described. This study should be helpful in identifying the specific vessels and bile ducts of the areas of the medial segment to be resected and to be preserved, thereby facilitating resection of the medial segment.

Adult↗

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Ultrastructural study of the remnant liver after extensive hepatectomy in dogs; especially morphological alterations of sinusoidal endothelial cells.

BACKGROUND/AIMS: To investigate the role of sinusoidal endothelial cells in the mechanism of the remnant liver dysfunction after extensive hepatectomy, morphological alteration of sinusoidal endothelial cells and cytoprotective effects of prostaglandin I2 analog were studied by ultrastructural analysis. METHODOLOGY: Mongrel dogs (n = 24) were divided into 3 groups according to the extent of hepatectomy and the use of prostaglandin I2 analog preoperatively. Group 1: 70% hepatectomy (n = 8), Group 2: 84% hepatectomy (n = 8), and Group 3: 84% hepatectomy with administration of prostaglandin I2 analog, preoperatively (n = 8). Morphology of hepatic sinusoidal endothelial cells was examined after hepatectomy in all cases. RESULTS: Group 2: Enlargement of the sinusoidal endothelial fenestrations was transitorily occurred immediately after hepatectomy, but were dramatically decreased in size 24 h after the operation. Most sinusoidal endothelial cells were destroyed and separated from the sinusoidal wall. Fibrin deposits and sludge were found in the Disse's space and sinusoidal lumens, resembling liver failure at 24 h after the operation. Group 1 and 3: sinusoidal endothelial fenestrations remained slightly enlarged at 24 h after the operation, but fibrin deposits or sludge were not observed in sinusoidal lumens. CONCLUSIONS: Our data suggest that extensive hepatectomy changed the morphology of sinusoidal endothelial cells. Administration of prostaglandin I2 analog helped maintain structural integrity of sinusoidal endothelial cells, improved hepatic microcirculation and thus served to reduce remnant liver dysfunction.

Animals↗